Symptoms Questionnaire

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)

Email(Required)

Phone(Required)

Your Gender:(Required)

Female

Male

Date of Birth:(Required)

Please choose the closest location:(Required)

Fredericksburg, VA

Greenville, SC

Richmond, VA

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

	0	1	2	3	4	5	6	7	8	9	10
Painful Intercourse
Night Sweats
Hot Flashes
Dry Skin
Chronic Fatigue
Restless Leg Syndrome
Hair Loss

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

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

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

Symptoms Questionnaire

Existing Patient Symptoms Questionnaire

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