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Women’s Signature
Hormone Assessment
Women’s Signature Hormone Assessment
1.
How often do you experience night sweats?
Often
Sometimes
Never
2.
Have you recently experienced any memory or concentration changes?
Yes
Not Sure
No
3.
How often do you experience hot flashes?
Often
Sometime
Never
4.
Have you recently experienced unexplained mood swings or depression?
Yes
Not Sure
No
5.
How often do you experience feelings anxiety?
Often
Sometimes
Never
6.
Have you recently experienced weight gain?
Yes
Not Sure
No
7.
Do you have trouble sleeping, unrelated to stress or other influencing factors?
Often
Sometimes
Never
8.
Do you struggle with chronic fatigue, unrelated to physical exertion?
Often
Sometimes
Never
9.
Have you experienced a recent unexplained loss of sex drive?
Yes
No
Not Sure
10.
Do you experience vaginal dryness or painful intercourse?
Yes
Note Sure
No
11.
How often do you experience heart palpitations (which are not part of a chronic condition)?
Often
Sometimes
Never
Your Full Name
To what email address may we send your results?
Enter your phone # if you would like us to call you to discuss your results.
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