bhrt-health-form-women - PRIME MEDICAL SPA

BIOIDENTICAL HORMONE REPLACEMENT THERAPY

Women's Health Assessment Questionnaire

Please complete the assessment to the best of your ability—one of our specialists will review your responses and happily answer any questions you may have. A team member will follow up to schedule your initial appointment, discuss next steps, and coordinate any necessary lab work.

First and Last Name

Email Address

Phone Number

Physical Exhaustion (fatigue, lack of energy, stamina or motivation)

None Mild Moderate Severe Very Severe

Sleep Problems (difficulty falling asleep or sleeping through the night)

None Mild Moderate Severe Very Severe

Irritability (mood swings, feeling aggressive, angers easily)

None Mild Moderate Severe Very Severe

Anxiety (feeling overwhelmed, feeling panicky, or feeling nervous)

None Mild Moderate Severe Very Severe

Decline in drive or interest (loss of “zest for life,” feeling down or sad)

None Mild Moderate Severe Very Severe

Joint and muscular symptoms (joint pain, muscle weakness, poor recovery after exercise)

None Mild Moderate Severe Very Severe

Difficulties with memory (concentration, finding the right word, or retaining information)

None Mild Moderate Severe Very Severe

Vaginal dryness or difficulty with sexual intercourse

None Mild Moderate Severe Very Severe

Sexual Problems (change in desire, activity, orgasm and/or satisfaction)

None Mild Moderate Severe Very Severe

Sweating (night sweats or increased episodes of sweating)

None Mild Moderate Severe Very Severe

Hot Flashes (burst that starts in chest and lasts for short duration)

None Mild Moderate Severe Very Severe

Hair loss, thinning or change in texture of hair

None Mild Moderate Severe Very Severe

Feeling cold all the time, having cold hands or feet

None Mild Moderate Severe Very Severe

Headaches or migraines (increase in frequency or intensity)

None Mild Moderate Severe Very Severe

Weight (difficulty losing weight despite diet/exercise)

None Mild Moderate Severe Very Severe

Bladder problems (difficulty in urinating, increased need to urinate, incontinence)

None Mild Moderate Severe Very Severe

Other symptoms or unique health circumstances to take into consideration: