Bio-identical Hormones Test

BIO-IDENTICAL HORMONES TEST

Name

First Last

Email

Phone

Date of Birth

How did you find out about us?

Other

Select a choice(Required)

Male

Female

Have you noticed a loss of muscle mass, strength, or endurance?(Required)

Yes

No

Are you having more trouble then usual keeping weight off?(Required)

Yes

No

Do you feel like you've lost your self-confidence?(Required)

Yes

No

Has your interest in sex diminished?(Required)

Yes

No

Do you ever feel depressed(Required)

Yes

No

Do you have less energy than when you were 30?(Required)

Yes

No

Do you have trouble getting an erection?(Required)

Yes

No

Do you struggle more than ever controlling your temper?(Required)

Yes

No

Do you have difficulty concentrating or focusing?(Required)

Yes

No

Do you ever have hot flashes?(Required)

Yes

No

Do you ever have night sweats?(Required)

Yes

No

Have you gained weight in your abdomen, hips, buttocks, or thighs?(Required)

Yes

No

Do you ever feel more stressed / anxious / nervous than usual?(Required)

Yes

No

Do you have a hard time sleeping?(Required)

Yes

No

Do you find it harder to remember things?(Required)

Yes

No

Do you often feel depressed?(Required)

Yes

No

Have you lost your interest in sex?(Required)

Yes

No

Do you often feel irritable, angry, or impatient?(Required)

Yes

No

When you cough or sneeze, do you sometimes have urinary leakage?(Required)

Yes

No

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