Hormone Intake Assessment

Everybody's Health Regenerative Medicine has intiated a bioidentical hormones program.

Our goal is to create an awareness and understanding of the importance of these hormones and how their lack effects our body as we age.

The following assessment will help us to understand how best to get you back to your younger self.
Please fill out the form below and we will contact you to go over your health concerns.

* Name:
* Birthdate:
* Height in inches
* Weight in pounds
* Goal Weight in Pounds
* Street Address:
* City:
* State:
* Zip:
* Email:
* Phone:
* Sex
Male
Female
Other

*required information
* Preferred Contact Method?
Telephone
Email

* Check the box if you have or have had any of the Estrogen Related issues below:
Hot Flashes/Night Sweats
Insomnia
Vaginal Dryness
Mental Fogginess
Memory Problems
Depression/ Irritability
Dry Skin and Brittle Nails
Fatigue
Migraine Headaches
Urinary Problems
Osteoporosis
Decreased Sexual Desire
None / Other
* Please Check the box if you have or have had and of the Progesterone Related issues below:
PMS Symptoms
Missed Periods
Rage, Deppression or Irritability
Breast Tenderness
Weight Gain
Dry Skin and Brittle Nails
Heavy Bleeding and Cramping/Clotting
Hair Loss
Infertility
Insomnia
Poor Focus / Concentration
Higher Bad Cholesterol
Fibromyalgia Symptoms
None / Other
* Please Check the box if you have or have had and of the Testosterone Related issues below:
Fatigue and or Loss of Zest for Life
Decreased Libido
Decreased Sexual Sensation
Decreased Energy
Weight Gain / Fat Gain
Osteoporosis
Loss of Strength / Endurance
Vaginal Dryness
Decreased Mental Clarity
Anxiety / Irritability
Loss of Muscle Tone / Mass
Aches and Pains
Stress / Depression
Sleep Disturbance
Cold Body Temperature
Prostate Enlargement
None / Other
Which of the above bothers you the most?
How long have you been dealing with it?
How often does it bother you?
What activities would you like to do if this was not a problem?
* What have you tried to solve this problem?
Medications
Exercise
Nothing
Natural Hormone Replacement
Nutrition
Chemical Hormone Therapies
Supplementation
Other