Hormone Replacement Therapy Online Assessment

Our goal is to create the optimum treatment for you.
Please answer the questions below to obtain your free Hormone Replacement Therapy Online Assessment.

Name:
Name

Email:
Email

Phone:
Phone

Date of Birth:
Date of Birth

Do you suffer from any medial conditions?
Do you suffer from any medical conditions?

Are you currently taking any medication?
Are you currently taking any medication?

Do you drink? How many drinks per week?
Do you drink? How many drinks per week?

Do you smoke? How many per day?
Are you currently taking any medication?

Are you currently taking any medication?
Do you smoke? How many per day?

Are you sexually active? How often do you have sex?
Are you sexually active? How often do you have sex?

Have you noticed a decrease in your sexual desire?
Have you noticed a decrease in your sexual desire?

(men) Do you wake with morning erections?
Do you exercise? How many times per week?

Have you noticed a decline in energy levels?
Have you noticed a decline in energy levels?

Have you noticed a decrease in motivation?
Have you noticed a decrease in motivation?

Do you tire easily or suffer from fatigue?
Do you tire easily or suffer from fatigue?

Do you have trouble sleeping? How many hours do you sleep on average?
Do you have trouble sleeping? How many hours do you sleep on average?

Have you noticed an increase in weight or fatty tissue?
Have you noticed an increase in weight or fatty tissue?

Do you suffer from irregular or negative mood swings?
Do you suffer from irregular or negative mood swings?

Do you find it difficult to deal with stressful situations?
Do you find it difficult to deal with stressful situations?

Have you noticed a change in your overall well being?
Have you noticed a change in your overall well being

Check For Symptoms:

Women:

Hot Flashes

Poor Sleep

Dry Skin

Mood Swings

Overly Emotional

Memory Loss

Night Sweats

Vaginal Dryness

Anxiety

Headaches

Painful Intercourse

Depression

Men:

Decreased Sex Drive

Tiredness

Restless Leg Syndrome

Loss of Pubic Hair

Loss of Muscle Mass

Muscle and Joint Pain

Lack of Self-Esteem

Insomnia

Weight Gain

Decreased Exercise Tolerance