Health Assessment Quiz Name * First Name Last Name Email * Phone * (###) ### #### Which of the following symptoms apply to you currently (in the past two weeks)? Please use a scale of 1 through 5. 1 = None 2 = Mild 3= Moderate 4 = Severe 5 = Very Severe Sweating (night sweats or increased episodes of sweating) * 1 -Never 2 -Mild 3 -Moderate 4 -Severe 5 -Very severe Depressed Mood (feeling down, sad, on the verge of tears, lack of drive) * 1 -Never 2 -Mild 3 -Moderate 4 -Severe 5 -Very severe Irritability (mood swings, feeling aggressive, angers easily) * 1 -Never 2 -Mild 3 -Moderate 4 -Severe 5 -Very severe Anxiety (inner restlessness, feeling panicky, nervous, inner tension) * 1 -Never 2 -Mild 3 -Moderate 4 -Severe 5 -Very severe Physical Exhuastion (fatigue, lack of energy, stamina or motivation, decreased stamina, endurance or muscle strength) * 1 -Never 2 -Mild 3 -Moderate 4 -Severe 5 -Very severe Sexual Problems (change in sexual desire, sexual activity, orgasm and/or satisfaction) * 1 -Never 2 -Mild 3 -Moderate 4 -Severe 5 -Very severe Vaginal Symptoms (decreased sensation, dryness or burning in the vagina, pain with sex) * 1 -Never 2 -Mild 3 -Moderate 4 -Severe 5 -Very severe Joint and Muscular Symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise) * 1 -Never 2 -Mild 3 -Moderate 4 -Severe 5 -Very severe Difficulties with memory, problems with thinking, concentrating or reasoning * 1 -Never 2 -Mild 3 -Moderate 4 -Severe 5 -Very severe Trouble thinking of the right word to describe someone or something. Trouble learning new things * 1 -Never 2 -Mild 3 -Moderate 4 -Severe 5 -Very severe Increase frequency or intensity of headaches or migraines * 1 -Never 2 -Mild 3 -Moderate 4 -Severe 5 -Very severe Hair loss, thinning or change in texture of hair * 1 -Never 2 -Mild 3 -Moderate 4 -Severe 5 -Very severe Feel cold all the time or have cold hands and feet * 1 -Never 2 -Mild 3 -Moderate 4 -Severe 5 -Very severe Weight gain or difficulty loosing weight despite a good diet and exercise * 1 -Never 2 -Mild 3 -Moderate 4 -Severe 5 -Very severe Dry or wrinkled skin * 1 -Never 2 -Mild 3 -Moderate 4 -Severe 5 -Very severe Constipation or irregular bowl movements (you go a day or more without a bowel movement) * 1 -Never 2 -Mild 3 -Moderate 4 -Severe 5 -Very severe Would you like to be added to our email list for updates, health tips and special offers only shared with our subscribers? (We will never share, sell or spam you and you can unsubscribe anytime) * Yes No Thank you!
