Hormone Imbalance Symptom Screen For Women EvexiPEL Symptom Screen – Female Name * Name First First Last Last Date of Birth * Phone * Email * Address City State Zip Code * Hot Flashes, Sweating (Episodes of Sweating) * None Mild Moderate Severe Very Severe Heart Discomfort (unusual awareness of heart beat, heart skipping, heart racing, tightness) * None Mild Moderate Severe Very Severe Sleep Problems (difficulty in falling asleep, sleeping through the night, waking early) * None Mild Moderate Severe Very Severe Depressive Mood (feeling down, sad, on the verge of tears, lack of drive, mood swings) * None Mild Moderate Severe Very Severe Irritability (feeling nervous, inner tension, feeling aggressive) * None Mild Moderate Severe Very Severe Anxiety (inner restlessness, feeling panicky) * None Mild Moderate Severe Very Severe Physical and Mental Exhaustion (decreased performance, concentration, memory, forgetfulness) * None Mild Moderate Severe Very Severe Sexual Problems (change in sexual desire, in sexual activity, and satisfaction) * None Mild Moderate Severe Very Severe Bladder Problems (difficulty urinating, increased urination, bladder incontinence) * None Mild Moderate Severe Very Severe Dryness of Vagina (sensation of dryness/burning, difficulty with sexual intercourse) * None Mild Moderate Severe Very Severe Joint and Muscular Discomfort (pain in the joints, rheumatoid complaints) * None Mild Moderate Severe Very Severe Please share any additional comments about your symptoms. 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. (Activity that raises heart rate & breathing) * 0 – 1 day/week (low) 2 -3 days/week (average) More than 3 days/week (high) Please list any prior hormone therapy * If you are human, leave this field blank. Submit Δ