Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Preventative care *

List all that apply

Medical/GYN Exam in the last year

Mammogram in the last 12 months

Bone Density in the last 12 months

Pelvic ultrasound in the last 12 months

None

Hormone Assessment *

Do you experience any of the following? (Check all that apply)

Hot flashes

Sweating

Heart discomfort

Sleep problems

Depressive mood

Irritability

Anxiety

Physical exhaustion

Sexual problems

Bladder problems

Dryness of vagina

Joint Discomfort

Muscular Discomfort

Mental exhaustion

Brain Fog

Cold (hands and feet, or temperature intolerance)

Constipation

Dry skin or hair

Brittle hair or nails

Hair loss

Weight gain

Inability to lose weight

No symptoms, I feel amazing

How long have you been experiencing these symptoms? *

Less than a month

Between 1 and 6 months

Longer than 6 months

Are you currently experiencing pain? *

Yes

No