Female Hormone Symptom Evaluation First name*Surname*Date of birth* Date Format: DD slash MM slash YYYY Phone number*Symptom evaluationPlease fill out this questionnaire prior to your consultation by indicating the severity of the symptoms in the list below by using the following rating: ABSENT=0, MILD=1, MODERATE=2, SEVERE=3Date* Date Format: DD slash MM slash YYYY Hot Flashes*0123Night Sweats*0123Vaginal Dryness*0123Urinary Incontinence*0123Bleeding Changes*0123Fibrocystic Breasts*0123Weight Gain*0123Fluid Retention*0123Dry Skin/Hair*0123Hair Loss*0123Anxiety*0123Depression*0123Mood Swings*0123Irritability*0123Headaches*0123Breast Tenderness*0123Cramps*0123Difficulty Falling Asleep*0123Difficulty Staying Asleep*0123Fatigue*0123Loss of Memory*0123Foggy Thinking*0123Acne*0123Arthritis*0123Decreased Sex Drive*0123Difficulty Reaching Orgasm*0123Difficulty with Sexual Arousal*0123Pain or Dryness on Intercourse*0123Stress*0123Score* I confirm that the information I have given above is accurate, I understand that giving inaccurate information could compromise the safety and appropriateness of the treatment that the doctor would be prescribing for me. In order to review the effectivity of our programme, we always advise to take before and after photos while using our programme. Please note that we might use your photos for promotional purposes. These will always remain anonymous. Patient Signature*Date* Date Format: DD slash MM slash YYYY Δ
