Biote-Women-Quiz | Svelte Medical Weight Loss

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Patient Symptom Assessment Checklist for Women

Which of the following symptoms apply to you currently (in the last 2 weeks)? Please mark the appropriate box
for each symptom. For symptoms that do not currently apply or no longer apply, mark “none”.

Symptom	Never	Mild	Moderate	Severe	Very Severe
Hot flashes	Never	Mild	Moderate	Severe	Very Severe
Sweating (night sweats or increased episodes of sweating)	Never	Mild	Moderate	Severe	Very Severe
Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early)	Never	Mild	Moderate	Severe	Very Severe
Depressive mood (feeling down, sad, on the verge of tears, lack of drive)	Never	Mild	Moderate	Severe	Very Severe
Irritability (mood swings, feeling aggressive, angers easily)	Never	Mild	Moderate	Severe	Very Severe
Anxiety (inner restlessness, feeling panicky, feeling nervous, inner tension)	Never	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)	Never	Mild	Moderate	Severe	Very Severe
Sexual problems (change in sexual desire, sexual activity, orgasm and/or satisfaction)	Never	Mild	Moderate	Severe	Very Severe
Bladder problems (difficulty in urinating, increased need to urinate, incontinence)	Never	Mild	Moderate	Severe	Very Severe
Vaginal symptoms (sensation of dryness or burning in vagina, difficulty with sexual intercourse)	Never	Mild	Moderate	Severe	Very Severe
Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)	Never	Mild	Moderate	Severe	Very Severe
Difficulties with memory	Never	Mild	Moderate	Severe	Very Severe
Problems with thinking, concentrating or reasoning	Never	Mild	Moderate	Severe	Very Severe
Difficulty learning new things	Never	Mild	Moderate	Severe	Very Severe
Trouble thinking of the right word to describe persons, places or things when speaking	Never	Mild	Moderate	Severe	Very Severe
Increase in frequency or intensity of headaches or migraines	Never	Mild	Moderate	Severe	Very Severe
Hair loss, thinning or change in texture of hair	Never	Mild	Moderate	Severe	Very Severe
Feel cold all the time or have cold hands or feet	Never	Mild	Moderate	Severe	Very Severe
Weight gain or difficulty losing weight despite diet and exercise	Never	Mild	Moderate	Severe	Very Severe
Dry or wrinkled skin	Never	Mild	Moderate	Severe	Very Severe

Family History	No	Yes
Heart Disease	No	Yes
Diabetes	No	Yes
Osteoporosis	No	Yes
Alzheimer's Disease	No	Yes
Breast Cancer	No	Yes

Personal History	No	If Yes, when
Hysterectomy	No	Yes
Breast Cancer	No	Yes
Uterine Cancer	No	Yes
Polycystic Ovaries	No	Yes
Fibrocystic Breast	No	Yes
Epilepsy	No	Yes
Stroke	No	Yes

Age

Weight

Smoker
YesNo

Last Menstrual Period

Birth Control

Thyroid Medication/dose

Current Hormone Replacement Therapy

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Patient Symptom Assessment Checklist for Women

Fill Out the Following Information to Find Out if BioTE Can Help.

Have You Experienced Moderate to Severe Symptoms of Any of the Following?