Hormone Replacement Therapy Quiz

Please Select Gender*
- Male
- Female
Female - Symptoms
Fatigue*
- Never
- Mild
- Moderate
- Severe
Mood Changes*
- Never
- Mild
- Moderate
- Severe
Decreased Mental Ability*
- Never
- Mild
- Moderate
- Severe
Hot Flashes / Night Sweats*
- Never
- Mild
- Moderate
- Severe
Weight Gain*
- Never
- Mild
- Moderate
- Severe
Decreased Sex Drive*
- Never
- Mild
- Moderate
- Severe
Sleep Problems*
- Never
- Mild
- Moderate
- Severe
Always Cold*
- Never
- Mild
- Moderate
- Severe
Hair Loss / Breakage*
- Never
- Mild
- Moderate
- Severe
Dry Wrinkled Skin*
- Never
- Mild
- Moderate
- Severe
Family History
Check All That Apply
- Heart Disease
- Diabetes
- Osteoporosis
- Alzheimer's Disease
- Breast Cancer
Male - Symptoms
Fatigue*
- Never
- Mild
- Moderate
- Severe
Mood Changes*
- Never
- Mild
- Moderate
- Severe
Decreased Mental Ability*
- Never
- Mild
- Moderate
- Severe
Excessive Sweating*
- Never
- Mild
- Moderate
- Severe
Weight Gain*
- Never
- Mild
- Moderate
- Severe
Decreased Sex Drive*
- Never
- Mild
- Moderate
- Severe
Sleep Problems*
- Never
- Mild
- Moderate
- Severe
Decreased Muscle Strength*
- Never
- Mild
- Moderate
- Severe
Hair Loss / Breakage*
- Never
- Mild
- Moderate
- Severe
Joint Pain / Muscle Aches*
- Never
- Mild
- Moderate
- Severe
Family History
Check All That Apply
- Heart Disease
- Diabetes
- Osteoporosis
- Alzheimer's Disease
- Prostate Cancer
How can we reach you?
Name*
Full Name
Email*
Phone