Female Consultation Request

First name
Last name
Phone
Email
Do you suffer from night sweats or hot flashes?
Yes No

Do you notice yourself feeling more stressed, anxious, or nervous lately?
Sometimes
Often
Always
Never

Have you gained weight especially in your abdomen, hips, buttocks, and thighs or have difficulty losing the weight?
Yes No

Do you have trouble sleeping?
Sometimes
Often
Always
Never

Do you find yourself having difficulty concentrating or focusing?
Sometimes
Often
Always
Never

Do you have less interest in sex?
Sometimes
Often
Always
Never

Do you feel irritated, inpatient, have outbursts of anger, or feel out of control with your emotions?
Sometimes
Often
Always
Never

Are you experiencing painful intercourse?
Yes No

What is your current age range?
Less than 35
35-40
41-45
46-50
51-55
56+