Hormone Balancing Therapy for Women (HRT) Patient Questionnaire

This questionnaire is designed to help us assess whether you are a suitable candidate for our Hormone Balancing Therapy (HRT) program and to tailor the right treatment plan for your hormonal health. Please answer all 20 questions accurately.

1 / 20

Are you experiencing hot flashes or night sweats?

2 / 20

Have you noticed changes in your sleep patterns, such as difficulty falling or staying asleep?

3 / 20

Do you experience sudden onset of anxiety, mood swings, or depression more than usual?

4 / 20

Have you experienced vaginal dryness or discomfort during intercourse?

5 / 20

Have you noticed a decrease in libido or sexual desire?

6 / 20

Do you experience frequent headaches or migraines?

7 / 20

Have you noticed changes in your weight or difficulty maintaining your current weight?

8 / 20

Are you experiencing hair thinning, dry skin, or brittle nails?

9 / 20

Do you feel fatigued or have low energy levels, even after a full night’s sleep?

10 / 20

Have you noticed a decrease in muscle mass or increased difficulty building or maintaining muscle despite exercise?

11 / 20

Are you experiencing increased body fat, particularly around the abdomen?

12 / 20

Do you have reduced endurance or stamina during physical activities?

13 / 20

Are you experiencing a general feeling of sluggishness or lack of motivation to engage in activities you once enjoyed?

14 / 20

Do you have difficulty falling asleep or staying asleep throughout the night?

15 / 20

Are you experiencing increased symptoms such as bloating, mood swings, or breast tenderness?

16 / 20

Do you feel anxious or irritable more often than usual?

17 / 20

Have you noticed more frequent headaches or migraines?

18 / 20

Are you experiencing bloating or water retention?

19 / 20

Do you have trouble concentrating or experience “brain fog”?

20 / 20

How regular are your menstrual cycles?

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