VEDA
Hormones I Weight Management I Peptides I Natural Aesthetics
Name
*
First Name
Last Name
Email
*
example@example.com
Age
*
General Hormone Health Check
Answer as best you can, these answers may change daily!
1. Physical Exhaustion (fatigue, lack of energy, stamina, or motivation)
NONE
1
2
3
4
VERY SEVERE
5
1 is NONE, 5 is VERY SEVERE
2. Sleep Problems (difficulty falling asleep, or sleeping through the night)
NONE
1
2
3
4
VERY SEVERE
5
1 is NONE, 5 is VERY SEVERE
3. Irritability (mood swings, feeling aggressive, angers easily)
NEVER
1
2
3
4
VERY SEVERE
5
1 is NEVER, 5 is VERY SEVERE
4. Anxiety (felling overwhelmed, feeling panicky, or feeling nervous)
NEVER
1
2
3
4
VERY SEVERE
5
1 is NEVER, 5 is VERY SEVERE
5. Decline in drive or interest (loss of "zest for life," feeling down or sad)
NEVER
1
2
3
4
VERY SEVERE
5
1 is NEVER, 5 is VERY SEVERE
6. Joint and muscular symptoms (joint pain, muscle weakness, poor recovery after exercise)
NEVER
1
2
3
4
VERY SEVERE
5
1 is NEVER, 5 is VERY SEVERE
7. Difficulties with memory (concentration, finding the right word, or retaining information information)
NEVER
1
2
3
4
VERY SEVERE
5
1 is NEVER, 5 is VERY SEVERE
8. FEMALES: Vaginal dryness MALES: Erectile dysfunction
NEVER
1
2
3
4
VERY SEVERE
5
1 is NEVER, 5 is VERY SEVERE
9. Sexual Problems (change in desire, activity, orgasm, and/or satisfaction)
NEVER
1
2
3
4
VERY SEVERE
5
1 is NEVER, 5 is VERY SEVERE
10. FEMALES: Sweating (night sweats or increased episodes of sweating)
NEVER
1
2
3
4
VERY SEVERE
5
1 is NEVER, 5 is VERY SEVERE
11. FEMALES: Hot Flashes (burst that starts in chest and last for short duration)
NEVER
1
2
3
4
VERY SEVERE
5
1 is NEVER, 5 is VERY SEVERE
12. Hair loss, thinning or change in texture of hair
NEVER
1
2
3
4
VERY SEVERE
5
1 is NEVER, 5 is VERY SEVERE
13. Weight (difficulty losing weight despite diet/exercise)
NEVER
1
2
3
4
VERY SEVERE
5
1 is NEVER, 5 is VERY SEVERE
Other symptoms you'd like VEDA to address?
Ready to feel like yourself again? Let our team schedule you for a free consultation today.
Conveniently located less than 1 mile from RHLL
Veda Aesthetics & Wellness
310-483-1241 - 2244 Pacific Coast Highway, Suite 203 - Lomita CA 90717
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