Bloom HRT Medical intake form

You can always press Enter⏎ to continue

Is HRT Right For Me?

1
Name
First Name
Last Name
2
Email
example@example.com
3
When was you last period?
A year or more ago.
6 months ago
Less than 6 months
Monthly or close to it
Hysterectomy
4
If still having periods what are they like?
Heavy flow
Light
Regular flow
Last forever
Constant/frequent brownish discharge
Lots of breakthrough bleeding but no real period
No periods
5
Which of the following do you experience regularly?
Hot flashes
Night sweats
Insomnia
Brain Fog
Bad Mood/Irritability
Depression
Anxiety
Frozen shoulder
Painful muscles
Fatigue
6
Any bladder or vaginal issues?
Leak urine when laugh, cough, sneeze
Have to pee constantly- can't hold it.
Started wearing pads for urine leakage
Wake up more than once to urinate
Frequent urinary tract infections
Frequent vaginal infections
Vaginal odor won't go away despite good hygiene
Dry vagina
Itchy vagina
Discolored skin around vagina
7
How is your libido?
Great
Could be better
Non-existant
Should be Empty:

Question Label

1 of 7See AllGo Back