Name: New Leaf Restorative Medicine
Address: 1985 Hendersonville Rd #110, Asheville, NC, 28803, US
Telephone: (828) 552-4668

Are you experiencing any of these symptoms? (1 of 3)

Please check the frequency of all that apply.

	Never	Some days	Most days	Every day
Lack of energy or feeling fatigued
Feeling an overall decline in general wellbeing
Joint & muscle aches or pain
Hot flashes and/or night sweats
Poor sleep or problems staying asleep

Are you experiencing any of these symptoms? (2 of 3)

Please check the frequency of all that apply.

	Never	Some days	Most days	Every day
Irritable, moody, nervous, or anxious
Depressed and/or lack of motivation or vitality
Decreased mental focus or memory
Weight gain regardless of diet and exercise
Sudden and rapid hair loss

Are you experiencing any of these symptoms? (3 of 3)

Please check the frequency of all that apply.

We'll only use this information to reach out and talk to you about your hormone treatment options - no spam here!

Name

First Last

Phone

Email

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	Never	Some days	Most days	Every day
Decreased sexual performance or low libido
Difficulty to climax sexually
Bloating or swelling
Breast tenderness
Newly occurring migraine headache

Hormone Wellness Checklist – Female

Fill out the following form to determine if your symptoms could be relieved with bioidentical hormone therapy.