Hormone Optimization Patient Survey
Please complete this survey to help us understand your symptoms, lifestyle, and goals related to hormone optimization.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Gender
*
Male
Female
Other / Prefer not to say
How would you rate the severity of the following symptoms over the past month?
*
Rows
None
Mild
Moderate
Severe
Fatigue
1
2
3
4
Mood changes (anxiety, depression)
5
6
7
8
Difficulty sleeping
9
10
11
12
Low libido
13
14
15
16
Weight changes
17
18
19
20
Hot flashes or night sweats
21
22
23
24
Brain fog or memory issues
25
26
27
28
How would you rate your overall energy levels?
*
Very Low
1
2
3
4
5
6
7
8
9
Very High
10
1 is Very Low, 10 is Very High
Please indicate any current or past medical conditions.
Thyroid disorders
Diabetes
Heart disease
Cancer
None
Other
Please list any medications or supplements you are currently taking.
Which lifestyle factors would you like to improve? (Select all that apply)
Sleep quality
Diet and nutrition
Physical activity
Stress management
Other
Briefly describe your goals for hormone optimization.
Submit Survey
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