Skip to content
Podcasts
Monthly Specials
Richmond,VA
Morristown,TN
Testimonials
Submit your Testimonial
YouTube
Patient Forms
Symptoms Questionnaire
Advanced Care Card
Top Menu
Cart
0
View Cart
Checkout
No products in the cart.
Subtotal:
$
0.00
View Cart
Checkout
Renew Me Today
Hormone Health Therapy Center
Home
Hormone Health Test
Hormone Therapy Services
Therapy for Women
BHRT for Women
Bio-identical Hormone Replacement Therapy
O-Shot
Therapy for Men
BHRT for Men
Bio-identical Hormone Replacement Therapy
About BHRT
About Bio-Natural Hormone Therapy
the Bioidentical Hormone Debate:
Why the FDA is Wrong About Testosterone
Personal Wellness
FOR MEN
Erectile Dysfunction Services
New
Renew Pulse
Sound Wave Technology
FREE E-Book on:
How to Improve Sexual Function in Men.
FOR WOMEN
New
Votiva by Inmode
Vaginal Rejuvenation
O-Shot
Restoring the female libido
Viveve
Morristown, TN
Simple Treatment for Vaginal Laxity
ANTI-AGING
New
MORPHEUS8
Skin Tightening
New
Glutathione
MIC Injections
Sermorelin Acetate Injections
Weight Loss
Weight Loss – Column 2
Weight Loss
Medically Monitored Weight Loss
MIC Injections
Aesthetics Services
Cosmetic Injections
Botox® Injections
Visibly smooth’s out wrinkles and lines
Dermal Fillers
Juvederm – xc • voluma® xc • volbella xc
KYBELLA
Chemical Peels
Skinprint Services
We now offer SkinPrint Services. Please call for details.
Back Acne Treatment
Facials
Customized Facials
Dermaplaning
Reduce the appearance of hyperpigmentation, laxity, dullness and skin imperfections
HydraFacial MD
Light Therapy
Microneedling & Skin Tightening
New
MORPHEUS8
Skin Tightening • Richmond Location Only
Body Contouring
NEW
Physiq Body Contouring
Richmond Location Only
Laser Hair Reduction
Offered at Richmond Location.
NEW
Motus AY Laser Hair Reduction Treatment
Richmond Location Only
SkinPrint
Cleansers
Balancing Facial Cleanser
Sensitive Skin Cleanser
CLARIFYING CLEANSER™
Purifying Cleanser™
Treatment Serums
GUARDIAN CALMING COMPLEX™
Revive;
Multi-Corrective Blemish Control Serum
3-D Bio-Peptide Serum
SPOT ON™
ACNE TREATMENT
Moisturizers
EYEdeal™
Eye Repair Crème
Repair & Restorative
Treatment Crème™
DEW RENEW™
MOISTURE RENEWAL MASK
B5 BLOOM™
HYDRATING FLUID
Lightening
RECOVER LIGHTENING COMPLEX™
Sunscreens
RADIANCE SHIELD™
UVA/UVB SUNSCREEN SPF 44
Blog
Hormone Replacement Therapy
Hormone Therapy
BHRT For Women
BHRT for Men
Erectile Dysfunction
Menopause
Low Testosterone
Weight Loss
Weight Loss
Aesthetics Skin Care
Cosmetic Injections
Eclipse Micropen
Laser Hair Removal
Blog articles
All Articles
Sexual/Physical Wellness
Podcasts
Podcasts
Contact Us
Fredericksburg, VA
Greenville, SC
Coming Soon!
Orlando, FL
Morristown, TN
Richmond, VA
Home
Hormone Health Test
Hormone Therapy Services
Therapy for Women
BHRT for Women
Bio-identical Hormone Replacement Therapy
O-Shot
Therapy for Men
BHRT for Men
Bio-identical Hormone Replacement Therapy
About BHRT
About Bio-Natural Hormone Therapy
the Bioidentical Hormone Debate:
Why the FDA is Wrong About Testosterone
Personal Wellness
FOR MEN
Erectile Dysfunction Services
New
Renew Pulse
Sound Wave Technology
FREE E-Book on:
How to Improve Sexual Function in Men.
FOR WOMEN
New
Votiva by Inmode
Vaginal Rejuvenation
O-Shot
Restoring the female libido
Viveve
Morristown, TN
Simple Treatment for Vaginal Laxity
ANTI-AGING
New
MORPHEUS8
Skin Tightening
New
Glutathione
MIC Injections
Sermorelin Acetate Injections
Weight Loss
Aesthetics Services
Cosmetic Injections
Botox® Injections
Visibly smooth’s out wrinkles and lines
Dermal Fillers
Juvederm – xc • voluma® xc • volbella xc
KYBELLA
Chemical Peels
Skinprint Services
We now offer SkinPrint Services. Please call for details.
Back Acne Treatment
Facials
Customized Facials
Dermaplaning
Reduce the appearance of hyperpigmentation, laxity, dullness and skin imperfections
HydraFacial MD
Light Therapy
Microneedling & Skin Tightening
New
MORPHEUS8
Skin Tightening • Richmond Location Only
Body Contouring
NEW
Physiq Body Contouring
Richmond Location Only
Laser Hair Reduction
Offered at Richmond Location.
NEW
Motus AY Laser Hair Reduction Treatment
Richmond Location Only
SkinPrint
Cleansers
Balancing Facial Cleanser
Sensitive Skin Cleanser
CLARIFYING CLEANSER™
Purifying Cleanser™
Treatment Serums
GUARDIAN CALMING COMPLEX™
Revive;
Multi-Corrective Blemish Control Serum
3-D Bio-Peptide Serum
SPOT ON™
ACNE TREATMENT
Moisturizers
EYEdeal™
Eye Repair Crème
Repair & Restorative
Treatment Crème™
DEW RENEW™
MOISTURE RENEWAL MASK
B5 BLOOM™
HYDRATING FLUID
Lightening
RECOVER LIGHTENING COMPLEX™
Sunscreens
RADIANCE SHIELD™
UVA/UVB SUNSCREEN SPF 44
Blog
Hormone Replacement Therapy
Hormone Therapy
BHRT For Women
BHRT for Men
Erectile Dysfunction
Menopause
Low Testosterone
Weight Loss
Weight Loss
Aesthetics Skin Care
Cosmetic Injections
Eclipse Micropen
Laser Hair Removal
Blog articles
All Articles
Sexual/Physical Wellness
Podcasts
Podcasts
Contact Us
Fredericksburg, VA
Greenville, SC
Coming Soon!
Orlando, FL
Morristown, TN
Richmond, VA
You are here:
Home
Patient Forms
Symptoms Questionnaire
Symptoms Questionnaire
Step
1
of
4
25%
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:
*
First
Last
Email
*
Enter Email
Confirm Email
Phone
*
Your Gender:
*
Female
Male
Date of Birth:
*
MM slash DD slash YYYY
Please choose the closest location:
*
Fredericksburg, VA
Morristown,TN
Richmond, VA
Orlando, FL
Do you have a uterus?
Yes
No
How many times a week do you exercise?
Please select one.
I don't exercise
1
2
3
4
5
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.
(p)
0
1
2
3
4
5
6
7
8
9
10
Sleep Disturbances
Depression
Irritability
Anxiety
Mood Swings
Migraine Headaches
Palpitations
Comments, if any with the symptoms above
(E)
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
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.
(E)
1
2
3
4
5
6
7
8
9
10
Night Sweats
Hot Flashes
Dry Skin
Chronic Fatigue
Restless Leg Syndrome
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.
Breast Tenderness?
Yes
No
Bloating?
Yes
No
Bleeding/Spotting?
Yes
No
Comments, if any with the symptoms above
(T)
*
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 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.
(T)
*
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
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.
Are you satisfied with your last dosage of hormones?
Yes
No
Would you like your next dosage to be increased or decreased?
Increased
Decreased
Are you experiencing any acne or hair growth?
Comments, if any with the symptoms above
Patient Comments or any changes in medical conditions or medications since last report:
Go to Top
Boost your Immune System Help your body guard against virus’ with weekly Glutathione,
Vitamin D
& MIC treatments
Learn More
