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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
*
Ethnicity
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?
Female Medical History
Mammogram in last 12 months
Breast Cancer
Hysterectomy with removal of ovaries
Hysterectomy only
Smoker
Adult Acne
Chronic pain medication
ADD medication
Drug allergies
PCOS
Menstrual Cycle
No (been 12 months since last cycle)
Regular
Irregular
Irregular due to perimenopause
Birth Control Method (females)
Birth Control Pills
IUD
Progestin Shots
Implants
Other:
Patient Signature
Clear
