FEMALE HORMONE SYMPTOMS

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First Name
Last Name
Home Phone Number
Work Phone Number
Mobile Phone Number
Street Address
City
State
Zip Code
Date of Birth
Fibrocystic BreastAbsent
Mild
Moderate
Severe
Weight GainAbsent
Mild
Moderate
Severe
Heavy/Irregular MensesAbsent
Mild
Moderate
Severe
Hot FlashesAbsent
Mild
Moderate
Severe
Dry Skin/HairAbsent
Mild
Moderate
Severe
AnxietyAbsent
Mild
Moderate
Severe
DepressionAbsent
Mild
Moderate
Severe
Night SweatsAbsent
Mild
Moderate
Severe
Vaginal DrynessAbsent
Mild
Moderate
Severe
HeadachesAbsent
Mild
Moderate
Severe
IrritabilityAbsent
Mild
Moderate
Severe
Mood SwingsAbsent
Mild
Moderate
Severe
Breast TendernessAbsent
Mild
Moderate
Severe
Sleep Disturbances/InsomniaAbsent
Mild
Moderate
Severe
CrampsAbsent
Mild
Moderate
Severe
Fluid RetentionAbsent
Mild
Moderate
Severe
Breakthrough BleedingAbsent
Mild
Moderate
Severe
FatigueAbsent
Mild
Moderate
Severe
Loss of MemoryAbsent
Mild
Moderate
Severe
Bladder SymptomsAbsent
Mild
Moderate
Severe
ArthritisAbsent
Mild
Moderate
Severe
Harder to Reach ClimaxAbsent
Mild
Moderate
Severe
Decreased Sex DriveAbsent
Mild
Moderate
Severe
Hair LossAbsent
Mild
Moderate
Severe

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