Female BioTe- 1st Round
Name
First Name
Last Name
Age
Weight
Activity Level:
Low
Moderate
Average
High
Pregnant/Trying to Conceive?
Yes
No
Hysterectomy?
Yes
No
Still Menstruating?
Yes
No
Birth Control?
Yes
No
Smoker?
Yes
No
Currently on Hormone Replacement Therapy?
Yes
No
Currently on Thyroid medication?
Yes
No
History of Breast Cancer?
Yes
No
History of Epilepsy?
Yes
No
History of Endometriosis?
Yes
No
History of Fibrocystic Breast Disease?
Yes
No
History of PCOS?
Yes
No
History of Leiomyoma/Endometrial Polyps?
Yes
No
History of Hashimotos?
Yes
No
Preexisting Conditions Experienced:
Acne?
Yes
No
Breast Tenderness?
Yes
No
Facial Hair?
Yes
No
Premenstrual Migraine?
Yes
No
Hot Flashes?
Yes
No
Submit
Should be Empty: