Hormone Imbalance Questionnaire

How would you describe your energy levels throughout the day?

Do you experience mood swings or emotional fluctuations?

How is your sleep quality?

Have you observed changes in your skin, such as acne or dryness?

How is your libido or interest in sexual activities?

Do you frequently experience headaches or migraines?

How would you rate your overall well-being and sense of vitality?

Have you noticed any significant hair loss or thinning of your hair recently?

When was the last time you got your blood work done?

Are you currently under any form of hormonal treatment?

Please specify

What are your primary health goals?

Are you interested in proactive healthcare and preventative measures to optimize your health and longevity?

Do you stay active and prioritize healthy lifestyle habits like exercise and nutrition?

Would you be open to exploring evidence-based, cutting-edge therapies for anti-aging and wellness?

Are you comfortable providing recent blood work or participating in a comprehensive health assessment?

Do you believe in a collaborative approach to healthcare, working with medical professionals to achieve your goals?

Enter your zip code

We need to make sure your state allows telehealth.

Name

First

Last

Email

Phone

What is your sex?

How did you hear about us?

Please specify

If you heard about us from another source, please specify.

Our clinic is located in Hallandale, Florida, are you nearby?