WOMEN’S HORMONE DEFICIENCY SCREENING – BEFORE HRT
5301 Alpha Road Suite 34, Room 21 - Dallas, TX 75240 Phone: 214-890-6180 | Fax: 1-214-241-4792 Email: contact@jaenixmedspa.com
Your Information
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Full Name
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First Name
Last Name
Email Address
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Mobile Number
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Format: (000) 000-0000.
Age Range
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Please Select
18–29
30–39
40–49
50–59
60+
Date of Birth
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-
Month
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Day
Year
Date
MRS Symptom Checklist
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Rows
None
Mild
Moderate
Severe
Extremely Severe
1. Hot flashes, sweating (episodes of sweating)
2. Heart discomfort (unusual awareness of heart beat, heart skipping, heart racing, tightness)
3. Sleep problems (difficulty in falling asleep, difficulty in sleeping through the night, waking up early)
4. Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings)
5. Irritability (feeling nervous, inner tension, feeling aggressive)
6. Anxiety (inner restlessness, feeling panicky)
7. Physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness)
8. Sexual problems (change in sexual desire, in sexual activity and satisfaction)
9. Bladder problems (difficulty in urinating, increased need to urinate, bladder incontinence)
10. Dryness of vagina (sensation of dryness or burning in the vagina, difficulty with sexual intercourse)
11. Joint and muscular discomfort (pain in the joints, rheumatoid complaints)
Do you have cold hands and feet?
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Yes
No
Do you have daily bowel movements?
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Yes
No
Do you have gas, bloating, or abdominal pain after eating?
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Yes
No
Please select your WEEKLY Activity Level (Physical activity that accelerates heart rate or causes breathlessness)
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0-1 day per week (Low)
2-3 days per week (Average)
More than 3 days per week (High)
Please list any prior hormone therapy:
Please share any additional comments about your symptoms you would like to address.
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