Female Health Assessment

Name*

First Last

Email*

Phone*

When is it the best time to call?*

What is your age?

Symptom Checker

Please check any symptoms that are issues you would like addressed.

Vaginal Dryness

Yes
No

Hot Flashes

Yes
No

Night Sweats

Yes
No

Insomnia- falling Asleep

Yes
No

Insomnia- staying Asleep

Yes
No

Anxious

Yes
No

Depressed

Yes
No

Irritable

Yes
No

Mood Swings

Yes
No

Foggy Thinking

Yes
No

Poor Memory

Yes
No

Feel Cold

Yes
No

Dry Skin/Hair

Yes
No

Diffuse Pattern Hair Loss

Yes
No

Weight Gain/Inability to Lose Weight

Yes
No

Loss of Energy/Fatigue

Yes
No

Loss of Muscle Mass, Strength, or Tone

Yes
No

Lack of Confidence

Yes
No

Low Sex Drive

Yes
No

Difficulty Reaching Orgasm

Yes
No

Stress

Yes
No

Loss of Motivation

Yes
No

Feel Overwhelmed

Yes
No

Sugar Cravings

Yes
No

Craving Salty Foods

Yes
No

Water Retention/Swelling

Yes
No

Oily Skin/Acne

Yes
No

Increased Facial Hair

Yes
No

Please describe any other health concerns you may have or questions about services.

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Take this free symptom checker form to help us understand how best to address your concerns.

Symptom Checker

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