BioTE Health Assessment for Women

Name *

First

Last

Email *

Which of the following symptoms apply to you currently (in the last 2 weeks)? Please mark the appropriate box for each symptom. For symptoms that do not currently apply or no longer apply, mark "Never".

Hot Flashes *

Sweating (night sweats or increased episodes of sweating) *

Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early) *

Depressive mood (feeling down, sad, on the verge of tears, lack of drive) *

Irritability (mood swings, feeling aggressive, angers easily) *

Anxiety (inner restlessness, feeling panicky, feeling nervous, inner tension) *

Physical Exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina, or motivation *

Sexual problems, (change in sexual desire, in sexual activity and/or orgasm and satisfaction) *

Bladder problems (difficulty in urinating, increased need to urinate, incontinence) *

Vaginal Symptoms (sensation of dryness or burning in vagina, difficulty with sexual intercourse) *

Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise) *

Difficulties with memory *

Problems with thinking, concentrating, or reasoning *

Difficulty learning new things *

Trouble thinking of the right word to describe persons, places or things when speaking *

Increase in frequency or intensity of headaches or migraines *

Hair loss, thinning or change in texture of hair *

Feel cold all the time or have cold hands or feet *

Weight gain or difficulty losing weight despite diet and exercise *

Dry or wrinkled Skin *

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