Perimenopause Symptom Check — Serene Med Spa
Answer 15 quick questions about your last 3 months to see if a hormone consult may be helpful.
About you
What is your age range?
*
Under 35
35–39
40–44
45–49
50–54
55+
How have your periods been in the last year?
*
Regular, about the same as always
Cycles changing by a week or more
Skipping periods (60+ days between)
No period for 12+ months
I don't have periods (hysterectomy, IUD, or other reason)
Are you currently using hormonal birth control or hormone therapy?
Yes
No
Not sure
Symptoms (last 3 months)
Hot flashes or night sweats
*
Not at all
Mild
Moderate
Severe
Trouble falling or staying asleep
*
Not at all
Mild
Moderate
Severe
Heavier, longer or more irregular periods
*
Not at all
Mild
Moderate
Severe
Mood swings, irritability or tearfulness
*
Not at all
Mild
Moderate
Severe
Anxiety or feeling on edge
*
Not at all
Mild
Moderate
Severe
Brain fog, forgetfulness or trouble concentrating
*
Not at all
Mild
Moderate
Severe
Fatigue or low energy
*
Not at all
Mild
Moderate
Severe
Joint or muscle aches
*
Not at all
Mild
Moderate
Severe
Weight gain, especially around the middle
*
Not at all
Mild
Moderate
Severe
Lower sex drive
*
Not at all
Mild
Moderate
Severe
Vaginal dryness or discomfort with intimacy
*
Not at all
Mild
Moderate
Severe
Breast tenderness, bloating or headaches before periods
*
Not at all
Mild
Moderate
Severe
Which bothers you most right now?
Next step
How would you like to be seen?
*
Hudson, OH office
Barboursville, WV office
Telehealth video visit (Ohio, West Virginia, Kentucky or Florida)
First and last name
*
First Name
Last Name
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
*
example@example.com
Serene Med Spa · physician-led team · Hudson, OH · Barboursville, WV · Telehealth in OH, WV, KY & FL
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