Hormone Therapy Pre-Assessment for Women
Please take the following pre-assessment that can help determine your need for hormone therapy. All fields are required.
1. I am gaining weight and my clothes feel tighter.
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None
Mild
Moderate
Severe
2. I feel sluggish and tired more often.
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None
Mild
Moderate
Severe
3. I experience anxiety and become easily irritated.
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None
Mild
Moderate
Severe
4. I am less interested in sexual intimacy or have pain on intercourse.
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None
Mild
Moderate
Severe
5. I feel my excitement and zest for life is fading.
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None
Mild
Moderate
Severe
6. I often feel moody or depressed.
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None
Mild
Moderate
Severe
7. My skin looks thinner and more wrinkled or blemished.
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None
Mild
Moderate
Severe
8. I am forgetting names and facts more often - like where I put my keys.
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None
Mild
Moderate
Severe
9. It is harder for me to concentrate or hear or see clearly at times.
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None
Mild
Moderate
Severe
10. I experience "hot flashes" during the day or night sweats.
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None
Mild
Moderate
Severe
Full Name
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First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Gender
*
Select the preferred time for a FREE review with a patient representative:
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9am–12pm
12pm–3pm
3pm–6pm
When we receive your results we will place $50.00 on
your account towards a first visit with us!
Please verify that you are human
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