Female Intake Form

Your Name*

First Last

Date*

Your Phone Number*

Date of birth*

Your Email*

Which of our locations is best for you?*

Sorry, there are no more of this item.

1) Hot flashes, sweating (episodes of sweating)*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

2) Heart discomfort (unusual awareness of heart beat, heart skipping, heart racing, tightness)*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

3) Sleep problems (difficulty in falling asleep, difficulty in sleeping through the night, waking up early)*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

4) Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings)*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

5) Irritability (feeling nervous, inner tension, feeling aggressive)*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

6) Anxiety (inner restlessness, feeling panicky)*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

7) Physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness)*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

8) Sexual problems (change in sexual desire, in sexual activity and satisfaction)*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

9) Bladder problems (difficulty in urinating, increased need to urinate, bladder incontinence)*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

10) Dryness of vagina (sensation of dryness or burning in the vagina, difficulty with sexual intercourse)*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

11) Joint and muscular discomfort ( pain in the joints, rheumatoid arthritis)*

1) NONE
2) Mild
3) Moderate
4) Severe
5) Extremely Severe

Please share any addition comments about your symptoms you would like to address.

Please select your WEEKLY activity level based on this criteria --> Physical activity that accelerates heart rate / breathlessness*

0-1 Day Per Week (Low)
2-3 Days Per Week (Average)
3+ Days Per Week (High)

Do you have cold hands or feet?*

Yes
No

Do you have daily bowel movements?*

Yes
No

Do you have gas, bloating or abdominal pain after eating?*

Yes
No

Please list any prior hormone therapy?

Name

This field is for validation purposes and should be left unchanged.

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About Summit Medical Spa

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Location

63 East 800 North
Spanish Fork, UT 84660

3436 Pony Express Parkway, Suite 120
Eagle Mountain, UT 84005

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FEMALE MRS Checklist - Before HRT

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