Women’s Bioidentical Hormone Replacement

Health Assessment For Women (Female Symptom Questionnaire)

Take this brief health assessment to explore whether your symptoms may be related to hormone imbalance and if hormone replacement therapy might be a good fit for you. You deserve to feel like yourself again—this is a simple, yet meaningful first step toward restoring balance and well-being.

Name(Required)
MM slash DD slash YYYY
Best Time to Contact to Review
:

Symptoms

Which of the following symptoms apply to you currently (in the last 2 weeks)? Please mark the appropriate box for each symptom. For symptoms that do not currently apply or no longer apply mark "never".
Hot flashes
Sweating (night sweats or increased episodes of sweating)
Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early)
Depressive mood (feeling down, sad, on the verge of tears, lack of drive)
Irritability (mood swings, feeling aggressive, angers easily)
Anxiety (inner resltessness, feeling panicky, feeling 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, in sexual activity and/or orgasm and satisfaction)
Bladder problems (difficulty in urinating, increased need to urinate, incontinence)
Vaginal symptoms (sensation of dryness or burning in vagina, difficulty with sexual intercourse)
Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after excercise)
Difficulties with memory
Problems with thinking, concentrating and reasoning
Difficulty learning new things
Trouble thinking of the right word to describe persons, places or things when speaking
Increase in frequency or intensity of headaches or 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 and exercise
Dry or wrinkled skin

Severity Score Breakdown

Mild: 1-20 | Moderate: 21-40 | Severe: 41-60 | Very Severe: 61-80