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Hormone Wellness Checklist – Male
Fill out the following form to determine if your symptoms could be relieved with bioidentical hormone therapy.
Step
1
of
4
25%
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
Excessive sweating
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
Decreased muscle strength
Weight gain regardless of diet and exercise
Are you experiencing any of these symptoms? (3 of 3)
Please check the frequency of all that apply.
Never
Some days
Most days
Every day
Sudden and rapid hair loss
Decreased sexual performance or low libido
Breast development
Decreased morning erections
Poor or no results from ED medications
One last step before we calculate your score...
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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