BHRT CHECKLIST FOR WOMEN
Date:
*
-
Month
-
Day
Year
Date
Name:
*
Birthdate:
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Symptom (please check mark)
*
Rows
Never
Mild
Moderate
Severe
Depressive mood (feeling down/sad/lack of drive)
Memory Loss (forgetfulness)
Mental confusion (feeling in a mental fog)
Decreased sex drive/libido (decreased desire for sex)
Sleep problems (difficulty falling/staying asleep/wake up tired)
Mood changes/Irritability
Tension
Migraine/severe headaches
Difficult to climax sexually
Bloating
Weight gain
Breast tenderness
Vaginal dryness
Hot flashes
Night sweats
Dry and Wrinkled Skin
Hair is Falling Out
Cold all the time
Swelling all over the body
Joint pain
Other symptoms that concern you:
*
Submit
Should be Empty: