Female Hormone Symptom Evaluation First name*Surname*Date of birth* 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* DD slash MM slash YYYY Hot Flashes* 0 1 2 3 Night Sweats* 0 1 2 3 Vaginal Dryness* 0 1 2 3 Urinary Incontinence* 0 1 2 3 Bleeding Changes* 0 1 2 3 Fibrocystic Breasts* 0 1 2 3 Weight Gain* 0 1 2 3 Fluid Retention* 0 1 2 3 Dry Skin/Hair* 0 1 2 3 Hair Loss* 0 1 2 3 Anxiety* 0 1 2 3 Depression* 0 1 2 3 Mood Swings* 0 1 2 3 Irritability* 0 1 2 3 Headaches* 0 1 2 3 Breast Tenderness* 0 1 2 3 Cramps* 0 1 2 3 Difficulty Falling Asleep* 0 1 2 3 Difficulty Staying Asleep* 0 1 2 3 Fatigue* 0 1 2 3 Loss of Memory* 0 1 2 3 Foggy Thinking* 0 1 2 3 Acne* 0 1 2 3 Arthritis* 0 1 2 3 Decreased Sex Drive* 0 1 2 3 Difficulty Reaching Orgasm* 0 1 2 3 Difficulty with Sexual Arousal* 0 1 2 3 Pain or Dryness on Intercourse* 0 1 2 3 Stress* 0 1 2 3 This field is hidden when viewing the formScore* 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* DD slash MM slash YYYY Δ
