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Fill Out Required Boxes
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*Some Boxes May Not Pertain To Your Appointment Type
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Physical Exhaustion (fatigue, lack of energy, stamina or motivation)
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Irritability
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Sleep Problems (difficulty falling asleep or sleeping through the night)
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Anxiety (feeling overwhelmed, feeling panicky, or feeling nervous)
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Decline in drive or interest (loss of “zest for life,” feeling down or sad)
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Joint and muscular symptoms (joint pain, muscle weakness, poor recovery after exercise)
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Difficulties with memory (concentration, finding the right word, or retaining information)
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Sexual Problems (change in desire, activity, orgasm and/or satisfaction)
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Sweating (night sweats or increased episodes of sweating)
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Hair loss, thinning or change in texture of hair
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Feeling cold all the time, having cold hands or feet
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Headaches or migraines (increase in frequency or intensity)
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Weight (difficulty losing weight despite diet/exercise)
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Bladder problems (difficulty in urinating, increased need to urinate, incontinence)
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WOMENS- Vaginal dryness or difficulty with sexual intercourse
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WOMENS- Hot Flashes (burst that starts in chest and lasts for short duration)
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MENS- Erectile changes (weaker erections, loss of morning erections)
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MENS- Erectile changes (weaker erections, loss of morning erections)
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Other symptoms or unique health circumstances to take into consideration:
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