Hormone Optimization Questionnaire
Wellness from the inside out.
Radiant, lasting results come from health on the inside as much as the surface. The hormonal shifts that come with aging can quietly affect your energy, sleep, mood, skin quality, body composition, and how well you recover — often long before anything shows up on a routine visit. This brief, confidential questionnaire helps our APRN understand your symptoms and determine whether hormone optimization may help you look and feel your best.
YOUR INFORMATION
Full Name
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Date
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Date of Birth
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Month
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Day
Year
Date
Phone
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Format: (000) 000-0000.
SYMPTOM CHECK-IN
Rate by marking the box in which you feel relates to you the most.
Rows
None (0)
Mild (1)
Moderate (2)
Severe (3)
Persistent fatigue or low energy
Afternoon energy crashes
Unexplained weight gain or difficulty losing weight
Loss of muscle tone or physical strength
Difficulty falling or staying asleep
Waking unrefreshed / poor sleep quality
Night sweats
Irritability, anxiety, or mood swings
Low mood or loss of motivation
Brain fog, poor focus, or memory lapses
Thinning hair or hair loss
Dry, dull skin or loss of firmness beyond expected aging
Joint aches or stiffness
Back
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Rows
None (0)
Mild (1)
Moderate (2)
Severe (3)
Slower healing or recovery
Reduced libido
Vaginal dryness (women) or erectile changes (men)
Hot flashes
Irregular or changing menstrual cycles (women)
Feeling cold when others are comfortable
Reduced sense of wellbeing / "not feeling like yourself"
BRIEF HEALTH BACKGROUND
I have a personal or family history of a hormone-related condition (thyroid, etc.).
I am currently using hormone therapy or hormonal medication.
Current medications / supplements:
Your top goals:
SCHEDULE YOUR CONSULTATION WITH OUR ADVANCED PRACTICE REGISTERED NURSE
Ready to feel your best? The next step is a consultation with our Advanced Practice Registered Nurse, Melia Kramer, who will review your responses, discuss your goals, and determine whether baseline lab testing and a personalized hormone optimization plan are right for you.
I would like to schedule a consultation:
Yes, please contact me to schedule
Not at this time
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