Home . Symptoms Questionnaire

Symptoms Questionnaire

Complete your symptoms questionnaire to help us monitor your progress and adjust your treatment for the best possible results.

Existing Patients ONLY
Fill Out the Form

If you are a new patient, please do not fill out this form. Please click here to take the Hormone Health Test.

Step 1 of 4 - Patient Information

IMPORTANT: PLEASE SUBMIT THIS FORM TO RENEW TWO WEEKS PRIOR TO YOUR INSERT APPOINTMENT TO AVOID RESCHEDULING

This information is necessary for your Renew Provider to properly diagnose you in order to achieve and maintain therapeutic hormone levels. Thank you.

Patient Name:(Required)

First Last

Phone(Required)

Email(Required)

Enter Email Confirm Email

Gender:(Required)

Female

Male

Date of Birth:(Required)

MM slash DD slash YYYY

Choose The Location Nearest You(Required)

Richmond, VA

Fredericksburg, VA

Greenville, SC

Nashville, TN

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Do you have a uterus?

Yes

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How many times a week do you exercise?(Required)

For proper dosing, please rate your symptoms below based on how you are currently feeling: 0 means you have no symptoms of this type at all / 1 means you have very mild symptoms of this type 5 would be moderate symptoms and 10 would mean you have severe symptoms of this type.

Progesterone(Required)

	0	1	2	3	4	5	6	7	8	9	10
Sleep Disturbances
Depression
Irritability
Anxiety
Mood Swings
Migraine Headaches
Heart Palpitations

Comments, if any with the symptoms above

Estrogen for Women(Required)

	0	1	2	3	4	5	6	7	8	9	10
Painful Intercourse
Night Sweats
Hot Flashes
Vaginal Dryness
Urinary Incontinence/UTI
Restless Leg Syndrome
Hair Loss
Dry Skin

0 means you have no symptoms of this type at all / 1 means you have very mild symptoms of this type 5 would be moderate symptoms and 10 would mean you have severe symptoms of this type.

Estrogen for Men(Required)

	0	1	2	3	4	5	6	7	8	9	10
Night Sweats
Hot Flashes
Restless Leg Syndrome
Dry Skin

0 means you have no symptoms of this type at all / 1 means you have very mild symptoms of this type 5 would be moderate symptoms and 10 would mean you have severe symptoms of this type.

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Breast Tenderness?(Required)

Yes

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Bloating?(Required)

Yes

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Bleeding/Spotting?(Required)

Yes

Comments, if any with the symptoms above

Testosterone for Women(Required)

	0	1	2	3	4	5	6	7	8	9	10
Fatigue
Low Sex Drive
Memory Lapses/Brain Fog
Poor Focus /Concentration
Body Joint Pains
Low Exercise Tolerance
Loss of Muscle Tone

0 means you have no symptoms of this type at all / 1 means you have very mild symptoms of this type 5 would be moderate symptoms and 10 would mean you have severe symptoms of this type.

Testosterone for Men(Required)

	0	1	2	3	4	5	6	7	8	9	10
Fatigue
Low Sex Drive
Memory Lapses/Brain Fog
Poor Focus /Concentration
Body Joint Pains
Low Exercise Tolerance
Loss of Muscle Tone
Erectile Dysfunction

0 means you have no symptoms of this type at all / 1 means you have very mild symptoms of this type 5 would be moderate symptoms and 10 would mean you have severe symptoms of this type.

Comments, if any with the symptoms above

Patient Comments or any changes in medical conditions or medications since last report: