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Specialized Therapies:
* Joint Repair
* Hormone Optimization
* Peptides
LIFE ENHANCEMENT CLINICS OF MONTANA
Your Destination for Renewed Vitality!
Female Symptoms Checklist
Evexias Health Services
First Name
*
Last Name
*
Phone
*
Hot Flashes, sweating (episodes of sweating)
*
None
Mild
Moderate
Severe
Extremely Severe
Hot Flashes
Heart discomfort (unusual awareness of heart beat, heart skipping, heart racing, tightness)
*
None
Mild
Moderate
Severe
Extremely Severe
Heart Health
Sleeping Problems (difficulty in falling asleep, difficulty in sleelping thru the night, waking up early)
*
None
Mild
Moderate
Severe
Extremely Severe
Sleep
Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings)
*
None
Mild
Moderate
Severe
Extremely Severe
Mood
Irritability (feeling nervous, inner tension, feeling aggressive)
*
None
Mild
Moderate
Severe
Extremely Severe
Irritability
Anxiety (inner restlessness, feeling panicky)
*
None
Mild
Moderate
Severe
Extremely Severe
Anxiety
Physical & Mental exhaustion
*
None
Mild
Moderate
Severe
Extremely Severe
Exhaustion
Sexual problems (change in desire, sexual activity, satisfaction)
*
None
Mild
Moderate
Severe
Extremely Severe
Sexual Health
Bladder Problems
*
None
Mild
Moderate
Severe
Extremely Severe
Bladder
Vaginal Dryness (sensation of dryness or burning in vagina, difficulty with sexual intercourse)
*
None
Mild
Moderate
Severe
Extremely Severe
Joint & Muscle discomfort (pain in the joints, rheumatoid complaints)
*
None
Mild
Moderate
Severe
Extremely Severe
Joint & Muscle
Please share any additional comments about your symptoms you would like to address.
Do you have cold hands and feet?
*
Yes
No
Do you have daily bowel movements?
*
Yes
No
Do you have gas, bloating or abdominal pain after eating?
*
Yes
No
Please select your WEEKLY Activity Level based on this criteria: Physical activity that accelerates heart rate / Breathlessness
*
0-1 days/week (low)
2-3 days/week (average)
More than 3 days/week (high)
Please list any prior hormone therapy?
Patient Signature
Clear
