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* First Name

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* Last Name

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* Phone Number

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* Physical exhaustion (fatigue, lack of energy, stamina, exhaustion.

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* Sleep Problems (difficulty falling asleep or sleeping through the night)

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* Irritability (mood swings, feeling aggressive, angers easily)

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* Anxiety (feeling overwhelmed, feeling panicky, or feeling nervous)

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* Decline in drive or interest (loss of "zest for life," feeling down or sad)

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* Joint and muscular symptoms (joint pain, muscle weakness, poor recovery after exercise)

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* Difficulties with memory (concentration, finding the right word, or retaining information)

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* Sexual Desire or Performance (reduced or diminished)

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* Sexual problems (change in desire, activity, orgasm, and/or satisfaction)

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* Sweating (night sweats or increased episodes of sweating)

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* Hair loss, rapid or thinning

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* Feeling cold all the time, having cold hands or feet

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* Headaches or migraines (increase in frequency or intensity)

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* Weight (difficulty losing weight despite diet/exercise)

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* Bladder problems (difficulty in urinating, increased need to urinate, incontinence)

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* Thank you for taking our survey.

If you answered mild to severe to more than two of the symptoms listed on the survey you may be a potential candidate for hormone replacement therapy.

If you're interested in scheduling a Hormone Therapy consultation, please share a few upcoming dates and times that work for you, and we’ll do our best to find a convenient appointment.

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