BioTE Female Questionnaire

Name: Aurora Medical Spa
Rating: 5

Hormone Assessment for Women Choose which symptoms apply to you currently (in the last 2 weeks):

First Name* This field is required.

Last Name* This field is required.

Phone* This field is required.

Email* This field is required.

Nearest Location offering hormone replacement* This field is required.

Hot Flashes This field is required.

never

mild

moderate

severe

very severe

Sweating (night sweats or increased episodes of sweating) This field is required.

never

mild

moderate

severe

very severe

Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early) This field is required.

never

mild

moderate

severe

very severe

Depressive mood (feeling down, sad, lack of drive) This field is required.

never

mild

moderate

severe

very severe

Irritability (mood swings, feel aggressive, angers easily) This field is required.

never

mild

moderate

severe

very severe

Anxiety (inner restlessness, feeling panicky, feeling nervous, inner tension) This field is required.

never

mild

moderate

severe

very severe

Sexual problems (change in sexual desires, in sexual activity and/or orgasm and satisfaction) This field is required.

never

mild

moderate

severe

very severe

Bladder problems (difficulty in urinating, increased need to urinate) This field is required.

never

mild

moderate

severe

very severe

Vaginal symptoms (sensation or dryness or burning in vagine, difficulty with sexual intercourse) This field is required.

never

mild

moderate

severe

very severe

Joint and muscular symptoms (joint pain swelling, muscle weakness, poor recovery after exercise) This field is required.

never

mild

moderate

severe

very severe

Difficulties with memory This field is required.

never

mild

moderate

severe

very severe

Problems with thinking, concentrating or reasoning This field is required.

never

mild

moderate

severe

very severe

Difficulty learning new things This field is required.

never

mild

moderate

severe

very severe

Trouble thinking of the right word to describe persons, places or things when speaking This field is required.

never

mild

moderate

severe

very severe

Increase in frequency or intensity of headaches/migraines This field is required.

never

mild

moderate

severe

very severe

Rapid hair loss or thinning This field is required.

never

mild

moderate

severe

very severe

Feel cold all the time or have cold hands or feet This field is required.

never

mild

moderate

severe

very severe

Weight gain, increased belly fat, or difficulty losing weight despite diet and exercise This field is required.

never

mild

moderate

severe

very severe

Dry or wrinkled skin This field is required.

never

mild

moderate

severe

very severe

This field is required.

By completing this form, you are giving us permission to follow-up by phone, email or text.

This field is required.

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