Name*


DOB*

Email*


I am

Years Old

I Feel

Years Old.

SYMPTOMS : Rate your current status for each symptom by checking the appropriate box.

Absent Mild Moderate Severe
Headaches
Hot Flashes
Night Sweats
Low Libido
Inability to Reach Orgasm
Vaginal Dryness
Anxiety
Depression
Swollen Breasts
Fibrocystic Breasts
Moodiness
Food Disorders / Insomnia
Cramps
PMS
Heavy / Irregular Periods
Weight Gain
Water Retention / Bloating
Inability to Concentrate
Brain Fog
Fatigue/Lack of Energy
Heart Palpitations
Shortness of Breath
Dry Hair / Dry Skin
Cold Hands and Feet
Hair Loss
Joint Pain
High Cholesterol


Patient’s Signature

Date