PRE-SCREENING » FEMALE

 
Prefix: * City: *
First Name: * State: *
Middle Initial: Zip: *
Last Name: * Best Phone Number to Reach You: *
Date of Birth: * ( MM/DD/YYYY ) Best Time to Call You:  
E-mail: * Height: ( Ft )
Address 1:* Weight: ( Lbs )
Address 2: First Day of Last Menstrual Cycle: * ( MM/DD/YYYY )
 
 
What Are Your Chief Medical Complains? *
What Do You Expect to Achieve With an Anti-Aging Treatment? *
 
 
• BEHAVIOR NONE MILD MODERATE SEVERE
Nervous
Depressed
Stress
Irritable
Anxious
Mood Swings
Tearful
 
• MEMORY NONE MILD MODERATE SEVERE
Foggy Thinking
Memory Lapse
 
• ENERGY NONE MILD MODERATE SEVERE
Burned Out Feeling
Morning Fatigue
Evening Fatigue
Decreased Stamina
 
• HEART NONE MILD MODERATE SEVERE
Rapid Heartbeat
Heart Palpitations
Slow Pulse Rate
 
• BLOOD NONE MILD MODERATE SEVERE
High Blood Pressure
Low Blood Pressure
High Blood Sugar
Low Blood Sugar
High Cholesterol
Elevated Triglycerides
 
• SEXUAL DRIVE NONE MILD MODERATE SEVERE
Decreased Libido
Vaginal Dryness
Infertility Problems
 
• MUSCLES NONE MILD MODERATE SEVERE
Decreased Muscle Size
 
• SKIN / HAIR / NAILS NONE MILD MODERATE SEVERE
Acne
Thinning Skin
Hair Dry or Brittle
Nails Breaking or Brittle
 
• ACHES / PAIN NONE MILD MODERATE SEVERE
Headaches
Neck or Back Pain
 
• OTHERS NONE MILD MODERATE SEVERE
Sugar Cravings
Sleep Disturbed
Swelling or Puffy Eyes/Face
Cold Body Temperature
Numbness of Feet / Hands
Goiter
Bleeding Changes
Sensitivity to Chemicals
Bone Loss
Allergies
Hoarseness
Rapid Aging
Hearing Loss
Loss Scalp Hair
Increase Facial or Body Hair
Weight Gain - Hips
Weight Gain - Waist
Water Retention
Increased Urinary Urge
Incontinence
Constipation
Hot Flashes
Night Sweats
Decreased Sweating
Tender Breasts
Fibromyalgia
Fibrocystic Breasts
Uterine Fibroids
 
 
Do You Smoke? *
YES   NO
Explain:
Do You Drink Alcohol? *
YES   NO
Explain:
Do You Exercise? *
YES   NO
Explain:
Do You Wake Up Hungry? *
YES   NO
Comments:
Are You Hungry at Lunch Time? *
YES   NO
Comments:
What Do You Usually Eat During the Day? *
Do You Feel Sleepy in the Afternoon? *
YES   NO
Comments:
Do You Fall Asleep Fast? *
YES   NO
Comments:
How Many Times do You Wake Up During the Night? *
Explain:
How Many Hours of Uninterrupted Sleep do You Get Per Night? *
Do You Suffer From Chronic Skin Rash? *
YES   NO
Comments:
Do You Feel Wired at Bed Time? *
YES   NO
Comments:
How Did You Hear About Us? *
 
 
   

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