Request Information - Women Name * First Name Last Name Email * Phone (###) ### #### Preferred Contact Method Phone Text Email Best Time to Contact You Morning Afternoon Evening To what extent have you experienced any of the following: Hot Flashes Never Mild Moderate Severe Highly Severe Sweating (night sweats or increased episodes of sweating) Never Mild Moderate Severe Highly Severe Sleep problems (Difficulty falling asleep, sleeping through the night or walking up too early) Never Mild Moderate Severe Highly Severe Depressive mood (feeling down, sad, on the verge of tears, lack of drive) Never Mild Moderate Severe Highly Severe Irritability (mood swings, feeling aggressive, angers easily) Never Mild Moderate Severe Highly Severe Anxiety (inner restlessness, feeling panicky, feeling nervous, inner tension) Never Mild Moderate Severe Highly Severe Physical exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation) Never Mild Moderate Severe Highly Severe Sexual problems (change in sexual desire, sexual activity, orgasm and/or satisfaction) Never Mild Moderate Severe Highly Severe Bladder problems (difficulty in urinating, increased need to urinate, incontinence) Never Mild Moderate Severe Highly Severe Vaginal symptoms (sensation of dryness of dryness or burning in vagina, difficulty with sexual intercourse) Never Mild Moderate Severe Highly Severe Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise) Never Mild Moderate Severe Highly Severe Difficulties with memory Never Mild Moderate Severe Highly Severe Problems with focusing, concentration or reasoning Never Mild Moderate Severe Highly Severe Difficulty learning new things Never Mild Moderate Severe Highly Severe Trouble thinking of the right word to describe persons, places, or things when speaking Never Mild Moderate Severe Highly Severe Increase in frequency or intensity of headaches or migraines Never Mild Moderate Severe Highly Severe Hair loss, thinning or change in texture of hair Never Mild Moderate Severe Highly Severe Feel cold all the time or have cold hands or feet Never Mild Moderate Severe Highly Severe Weight gain or difficulty losing weight despite diet and exercise Never Mild Moderate Severe Highly Severe Dry or wrinkled skin Never Mild Moderate Severe Highly Severe How did you hear about us? Friend Social Media Internet search BioTe Website Other If Other, please explain Referral Did anyone refer you to us? Who can we thank? Newsletter Sign up Stay informed and subscribe to our monthly newsletter to receive exclusive content, sales, promotions and notifications! Sign me up! Not at this time This form collects your name, location, phone and email so we may contact you about your request. Please read our Privacy Policy to find out how we protect and manage your data. * I grant Advanced Health and Wellness Center consent to collect my contact information. Thank you!We will be in contact with you soon. info@advancedhealthandwellnesskalamazoo.com(269) 492-65061815 Henson Avenue Kalamazoo, MI49048
