Menopause & Hormone Wellness Assessment
This confidential assessment helps identify common hormone-related symptoms experienced during perimenopause and menopause. Your results will guide personalized supplement and wellness recommendations from Aesthetics of Fayetteville. This form is private and intended to support your comfort, balance, and overall well-being.
Symptom Assessment
How often do you currently experience the following symptoms? Please rate each symptom on a scale from 0 (None) to 4 (Extremely Severe).
How often do you currently experience the following symptoms?
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Rows
None (0)
Mild (1)
Moderate (2)
Severe (3)
Extremely Severe (4)
Hot flashes or sudden sweating
Heart racing, skipped beats, or chest tightness
Frequent urination or bladder leakage
Vaginal dryness or discomfort with intimacy
Trouble falling asleep or staying asleep
Low mood, sadness, or emotional swings
Irritability or inner tension
Anxiety or feeling on edge
Fatigue, brain fog, or poor concentration
Decreased sexual desire or satisfaction
Joint or muscle aches
Additional Wellness Questions
Do you often have cold hands or feet?
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Yes
No
Do you have daily bowel movements?
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Yes
No
How many days per week are you physically active?
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0–1 days per week
2–3 days per week
4 or more days per week
Do you experience gas, bloating, or abdominal discomfort after eating?
*
Yes
No
Have you used hormone therapy in the past? Please share details if comfortable.
Is there anything else you would like us to know about your symptoms?
Contact Information
First Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred contact method
*
Text
Email
Submit Assessment
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