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Modern Rejuvenation Center
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Home
About Us
Services
Aesthetics
Chemical Peel
Microblading
Microneedling
Body Sculpting
Hormone Therapy
BHRT
Women Hormone Therapy
Mens Hormone Therapy
Functional Medicine
Injectables
Botox
Fillers
Xeomin
Injectable Parties
What is PDO Thread Lift?
Memberships
Shop
Contact Us
Blog
BHRT Symptoms Questionnaire for Women
Step
1
of
3
33%
Hot Flashes
None
Mild
Moderate
Severe
Very Severe
Sweating (night sweats or increased episodes of sweating)
None
Mild
Moderate
Severe
Very Severe
Sleep problems (difficulty falling asleep, sleeping through the night, or waking up too early)
None
Mild
Moderate
Severe
Very Severe
Depressive mood (feeling down, sad, on the verge of tears, lack of drive)
None
Mild
Moderate
Severe
Very Severe
Irritability (mood swings, feeling aggressive, angers easily)
None
Mild
Moderate
Severe
Very Severe
Anxiety (inner restlessness, feeling panicky, feeling nervous, inner tension)
None
Mild
Moderate
Severe
Very Severe
Physical Exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation)
None
Mild
Moderate
Severe
Very Severe
Sexual problems (changes in sexual desire, sexual activity, orgasm and / or satisfaction)
None
Mild
Moderate
Severe
Very Severe
Bladder problems (difficulty in urinating, increased need to urinate, incontinence)
None
Mild
Moderate
Severe
Very Severe
Vaginal symptoms (sensation of dryness or burning in vagina, difficulty with sexual intercourse)
None
Mild
Moderate
Severe
Very Severe
Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)
None
Mild
Moderate
Severe
Very Severe
Difficulties with memory
None
Mild
Moderate
Severe
Very Severe
Problems with thinking, concentrating or reasoning
None
Mild
Moderate
Severe
Very Severe
Difficulty learning new things
None
Mild
Moderate
Severe
Very Severe
Trouble thinking of the right word to describe persons, places, or things when speaking
None
Mild
Moderate
Severe
Very Severe
Increase in frequency or intensity of headaches or migraines
None
Mild
Moderate
Severe
Very Severe
Hair Loss, thinning, or change in texture of hair
None
Mild
Moderate
Severe
Very Severe
Feel cold all the time or have cold hands or feet
None
Mild
Moderate
Severe
Very Severe
Weight gain or difficulty losing weight despite diet and exercise
None
Mild
Moderate
Severe
Very Severe
Dry or wrinkled skin
None
Mild
Moderate
Severe
Very Severe
Date
MM slash DD slash YYYY
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
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