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First and Last Name (Required.)

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Phone Number (Required.)

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Physical exhaustion (fatigue, lack of energy, stamina, exhaustion. (Required.)

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

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Irritability (mood swings, feeling aggressive, angers easily) (Required.)

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Anxiety (feeling overwhelmed, feeling panicky, or feeling nervous) (Required.)

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

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

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

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Vaginal dryness or difficulty with sexual intercourse (Required.)

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

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Sweating (night sweats or increased episodes of sweating) (Required.)

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Hot Flashes (burst that starts in chest and lasts for short duration) (Required.)

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Hair loss, thinning or change in texture of hair (Required.)

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Feeling cold all the time, having cold hands or feet (Required.)

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Headaches or migraines (increase in frequency or intensity) (Required.)

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Weight (difficulty losing weight despite diet/exercise) (Required.)

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

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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.

Or you can book online here: Schedule Hormone Therapy Consultation

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