First Name

Last Name

DOB

Email Address

Phone Number

I am __ Years Old

I Feel___Years Old.

Headaches Headaches Absent Mild Moderate Severe

Hot Flashes Hot Flashes Absent Mild Moderate Severe

Night Sweats Night Sweats Absent Mild Moderate Severe

Low Libido Low Libido Absent Mild Moderate Severe

Inability to Reach Orgasm Inability to Reach Orgasm Absent Mild Moderate Severe

Vaginal Dryness Vaginal Dryness Absent Mild Moderate Severe

Anxiety Anxiety Absent Mild Moderate Severe

Depression Depression Absent Mild Moderate Severe

Swollen Breasts Swollen Breasts Absent Mild Moderate Severe

Fibrocystic Breasts Fibrocystic Breasts Absent Mild Moderate Severe

Moodiness Moodiness Absent Mild Moderate Severe

Food Disorders / Insomnia Food Disorders / Insomnia Absent Mild Moderate Severe

Cramps Cramps Absent Mild Moderate Severe

PMS PMS Absent Mild Moderate Severe

Heavy / Irregular Periods Heavy / Irregular Periods Absent Mild Moderate Severe

Weight Gain Weight Gain Absent Mild Moderate Severe

Water Retention / Bloating Water Retention / Bloating Absent Mild Moderate Severe

Inability to Concentrate Inability to Concentrate Absent Mild Moderate Severe

Brain Fog Brain Fog Absent Mild Moderate Severe

Fatigue/Lack of Energy Fatigue/Lack of Energy Absent Mild Moderate Severe

Heart Palpitations Heart Palpitations Absent Mild Moderate Severe

Shortness of Breath Shortness of Breath Absent Mild Moderate Severe

Dry Hair / Dry Skin Dry Hair / Dry Skin Absent Mild Moderate Severe

Cold Hands and Feet Cold Hands and Feet Absent Mild Moderate Severe

Hair Loss Hair Loss Absent Mild Moderate Severe

Joint Pain Joint Pain Absent Mild Moderate Severe

High Cholesterol High Cholesterol Absent Mild Moderate Severe

Patient’s Signature

Date