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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+