HormonalHealthMD Self-Assessment

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The following assessment is your first step to a better and healthier life. This test will let us
know if you have been experiencing any of the following symptoms and their severity. Please score your symptoms on the following scale: 0 (none), 1 (mild), 2 (moderate), or 3 (severe).

Name *

Email *

Phone Number *

Primary Address *

Date of Birth *

YYYY

In-person or telemedicine visit? *

In-person

Telemedicine

Low Libido *

None

Severe

Depression *

None

Severe

Decreased Muscle Mass *

None

Severe

Sleep Disturbances *

None

Severe

Fatigue *

None

Severe

Bone Loss *

None

Severe

Memory Lapses *

None

Severe

Thinning Skin *

None

Severe

Incontinence *

None

Severe

Fibromyalgia *

None

Severe

Heart Palpitations *

None

Severe

Excessive Facial Hair *

None

Severe

Oily Skin *

None

Severe

Excessive Body Hair *

None

Severe

Hair Loss on Scalp *

None

Severe

Increased Acne *

None

Severe

Irritability *

None

Severe

Breast Cancer (Family included) *

None

Severe

Elevated Triglycerides *

None

Severe

Chemical Sensitivity *

None

Severe

Cold Body Temperature *

None

Severe

Sugar Cravings *

None

Severe

Moody *

None

Severe

Allergies *

None

Severe

Arthritis *

None

Severe

Stress *

None

Severe

Aches and Pains *

None

Severe

Headaches *

None

Severe

Perspiration *

None

Severe

Anxiety *

None

Severe

Tired or Exhausted *

None

Severe

Nails Brittle or Breaking *

None

Severe

Cold Hands and Feet *

None

Severe

Dry and Brittle Hair *

None

Severe

Dry Skin and Hair *

None

Severe

Hoarseness *

None

Severe

Slowed Reflexes *

None

Severe

Infertility Problems *

None

Severe

Constipation *

None

Severe

Decreased Sweating *

None

Severe

Mood Changes *

None

Severe

Swelling Puffy Eyes or Face *

None

Severe

Low Blood Pressure *

None

Severe

Slow Pulse Rate *

None

Severe

Rapid Heart Rate *

None

Severe

Sweaty *

None

Severe

Agitated *

None

Severe

Hot Feelings *

None

Severe

Weight Loss *

None

Severe

Difficulty Concentrating *

None

Severe

Forgetful *

None

Severe

Weight Gain *

None

Severe

Elevated Cholesterol *

None

Severe

Nervousness *

None

Severe

Slow Ankle Reflex *

None

Severe

Weight Loss Difficulty *

None

Severe

Thinning Pubic Hair *

None

Severe

Question or concerns?

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