BioTE Hormone Questionnaire

Use this questionnaire so that you can discuss your symptoms with Dr. Adamcik, and see what BioTE can do for you!

    HORMONAL ASSESSMENT

    Please indicate if you have any of the following symptoms

    Hot Flashes
    MildModerateSevereVery Severe

    Sweating (night sweats or increased episodes of sweating)
    MildModerateSevereVery Severe

    Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early)
    MildModerateSevereVery Severe

    Depressive Mood (feeling down, sad, on the verge of tears, lack of drive)
    MildModerateSevereVery Severe

    Irritability (mood swings, feeling aggressive, angers easily)
    MildModerateSevereVery Severe

    Anxiety (inner restlessness, feeling panicky, feeling nervous, inner tension)
    MildModerateSevereVery Severe

    Physical exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation)
    MildModerateSevereVery Severe

    Sexual problems (change in sexual desire, sexual activity, orgasm and/or satisfaction)
    MildModerateSevereVery Severe

    Difficulties with memory
    MildModerateSevereVery Severe

    Problems with thinking, concentrating or reasoning
    MildModerateSevereVery Severe

    Hair loss, thinning or change in texture
    MildModerateSevereVery Severe

    Feel cold all the time or have cold hands or feet
    MildModerateSevereVery Severe

    Weight gain or difficulty losing weight despite diet and exercise
    MildModerateSevereVery Severe

    Dry or wrinkled skin
    MildModerateSevereVery Severe