BioTE® Female Health Assessment

Which of the following symptoms apply to you currently within the last 2 weeks? Please mark the appropriate box for each symptom. For symptoms that do not currently apply or no longer apply, mark “none”.

Name *

Email Address *

Date of birth *

Hot flashes

Sweating (night sweats or increased episodes of sweating)

Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early)

Depressive mood (feeling down, sad, on the verge of tears, lack of drive)

Irritability (mood swings, feeling aggressive, angers easily)

Anxiety (inner restlessness, feeling panicky, feeling nervous, inner tension)

Physical exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation)

Sexual problems (change in sexual desire, sexual activity, orgasm and/or satisfaction)

Bladder problems (difficulty in urinating, increased need to urinate, incontinence)

Vaginal symptoms (sensation of dryness or burning in vagina, difficulty with sexual intercourse)

Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)

Difficulties with memory

Problems with thinking, concentrating or reasoning

Difficulty learning new things

Trouble thinking of the right word to describe persons, places or things when speaking

Increase in frequency or intensity of headaches or migraines

Hair loss, thinning or change in texture of hair

Feel cold all the time or have cold hands or feet

Weight gain or difficulty losing weight despite diet and exercise

Dry or wrinkled skin

BioTE® Female Health Assessment

Get in Touch

Address

Phone

Insurances Accepted

Hours

Membership Plans