Women's Health & Vitality Assessment

Women's Health Assessment

Which of the following symptoms apply to you currently (in the last 2 weeks)? Please make the appropriate selection for each symptom down below. For symptoms that do not currently apply or no longer apply, mark "none".

First Name *
Last Name *

Email *

Mobile Phone *

Symptoms

Hot Flashes *

Sweating (night sweats or excessive sweating) *

Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early) *

Depressive Mood (feeling down, sad, lacking drive) *

Irritability (mood swings, feeling aggressive, angers easily) *

Anxiety (inner restlessness, panicked, nervous, inner tension) *

Physical Exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation) *

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

Bladder Problems (difficulty or increased need to urinate, incontinence)) *

Vaginal Symptoms (sensation of dryness or burning in vagina, difficulty with sexual intercourse) *

Joint & Muscle Symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise) *

Difficulties with Memory *

Problems with thinking, concentrating, or reasoning *

Difficulty learning new things *

Trouble thinking of right word to describe person/place/things when speaking *

Increase in frequency or intensity of headaches/migraines *

Hair loss, thinning or change in texture of hair *

Feel cold all the time or have cold hands or feet *

Weight gain or difficulty losing weight despite diet/exercise *

Dry or Wrinkled Skin *

NOTE: Please add up your score and enter it below.

Total Score *

Severity Score: Mild 1-20 / Moderate: 21-40 / Severe: 41-60 / Very Severe: 61-80

Questions About Hormone Optimization?

Call Now To Speak With Our Physician

Women's Health & Vitality Assessment

Questions About Hormone Optimization?

Join Our Free Trial