Northpoint Aesthetics
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Hormone Health Assessment for Women
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Hormone Health Assessment for Women
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Email Address
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Date
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"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'."
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Never (0)
Mild (1)
Moderate (2)
Severe (3)
Very Severe (4)
Hot flashes
Sweating (night sweats or increased episodes of sweating)
Sleep problems
Depressive mood
Irritability
Anxiety
Physical exhaustion
Sexual problems
Bladder problems
Vaginal symptoms
Joint and muscular symptoms
Difficulties with memory
Problems with thinking, concentrating or reasoning
Difficulty learning new things
Trouble thinking of the right word
Increase in frequency/intensity of headaches or migraines
Hair loss, thinning or change in texture
Feel cold all the time / cold hands or feet
Weight gain or difficulty losing weight
Dry or wrinkled skin
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Hormone Health Assessment for Women
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