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Is BioTE Right for You?

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?


    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


    YesNo

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