Date

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Best Contact Number

(###)

###

####

Have you taken any hormones in the past?

Yes

No

Do you feel more fatigued and/or tired than usual?

Yes

No

Have you noticed a decrease in your muscle mass?

Yes

No

Have you experienced a loss in muscle strength?

Yes

No

Have you noticed an increase in your waist size?

Yes

No

Do you have trouble losing weight?

Yes

No

Do you have a decrease in your sex drive?

Yes

No

Have you experienced changes in your usual sleep pattern?

Yes

No

Have you had trouble concentrating?

Yes

No

Do you experience less enjoyment in personal interests and hobbies?

Yes

No

Is intercourse painful?

Yes

No

Normal results?

Yes

No

Are you experiencing vaginal dryness or painful intercourse?

Yes

No

Are you experiencing higher levels of anxiety?

Yes

No

Are you having hot flashes or night sweats?

Yes

No

Are you suffering from hair loss?

Yes

No

Is your sleep quality good? (Do you wake up feeling refreshed in the morning?)

Yes

No

Agreement *

By submitting this survey, you are agreeing to allow Dr. Riske to review your medical information and acknowledging that this information is being sent over email servers and is not encrypted.

Acknowledged