First Name
Last Name
Date of birth
Phone
*
Email
*
Hot flashes, sweating (episodes of sweating)
None
Mild
Moderate
Severe
Extremely Severe
Heart discomfort (unusual awareness of heart beat, heart skipping, heart racing, tightness)
None
Mild
Moderate
Severe
Extremely Severe
Sleep problems (difficulty in falling asleep, difficulty in sleeping through the night, waking up early)
None
Mild
Moderate
Severe
Extremely Severe
Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings)
None
Mild
Moderate
Severe
Extremely Severe
Irritability (feeling nervous, inner tension, feeling aggressive)
None
Mild
Moderate
Severe
Extremely Severe
Anxiety (inner restlessness, feeling panicky)
None
Mild
Moderate
Severe
Extremely Severe
Physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness)
None
Mild
Moderate
Severe
Extremely Severe
Sexual problems (change in sexual desire, in sexual activity and satisfaction)
None
Mild
Moderate
Severe
Extremely Severe
Bladder problems (difficulty in urinating, increased need to urinate, bladder incontinence)
None
Mild
Moderate
Severe
Extremely Severe
Dryness of vagina (sensation of dryness or burning in the vagina, difficulty with sexual intercourse)
None
Mild
Moderate
Severe
Extremely Severe
Joint and muscular discomfort (pain in the joints, rheumatoid complaints)
None
Mild
Moderate
Severe
Extremely Severe
Please share any additional comments about your symptoms you would like to address.
Do you have cold hands and feet?
Yes
No
Do you have daily bowel movements?
Yes
No
Do you have gas, bloating or abdominal pain after eating?
Yes
No
Physical activity that accelerates heart rate / Breathlessness
0-1 day per week (Low)
2-3 days per week (Average)
More than 3 days per week (High)
Please list any prior hormone therapy?
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APPT DATE