Hormone Therapy Assessment Step 1 of 3 0% Please fill out the following medical assessment . The information you provide will assist the medical provider in determining the most appropriate course of treatment for you.Name(Required) First Last Phone(Required)Email(Required) Date of Birth(Required) MM slash DD slash YYYY Gender(Required) Male Female Menopause Symptoms(Required)YesNoAre you an epic Fitness member ?(Required) Yes No Select Location(Required)-- Select Location --St. PetersburgBrooksvillePort RicheySpring HillWeeki Wachee You're about to take the first step to restoring your life and health. By taking the test, you're heading in the right direction to becoming a better you! Get started by letting us know if you've been experiencing any of the following symptoms and the severity of your suffering. Please score your symptoms as follows: 0 = none, 1 = mild, 2 = moderate, 3 = severeAndropause SymptomsAndropause, sometimes called “male menopause,” happens when testosterone and other hormones decline with age. Common symptoms include:How often do you experience low energy or fatigue during the day?(Required) 0 1 2 3 Have you noticed reduced muscle strength compared to before?(Required) 0 1 2 3 Have you experienced weight gain, especially around the waist?(Required) 0 1 2 3 Do you have low libido or erectile changes?(Required) 0 1 2 3 How often do you experience mood swings, irritability, or depression?(Required) 0 1 2 3 Do you have trouble falling or staying asleep?(Required) 0 1 2 3 Have you noticed memory or concentration problems?(Required) 0 1 2 3 Do you feel a loss of motivation or drive?(Required) 0 1 2 3 General QuestionsLow Libido(Required) 0 1 2 3 Muscle Mass(Required) 0 1 2 3 Fatigue(Required) 0 1 2 3 Bone Loss(Required) 0 1 2 3 Thinning Skin(Required) 0 1 2 3 Memory Lapses(Required) 0 1 2 3 Incontinence(Required) 0 1 2 3 Fibromyalgia(Required) 0 1 2 3 Heart Palpitations(Required) 0 1 2 3 Oily Skin(Required) 0 1 2 3 Excessive Body Hair(Required) 0 1 2 3 Hair Loss On Scalp(Required) 0 1 2 3 Increased Acne(Required) 0 1 2 3 Breast Cancer (Yourself Or Family)(Required) 0 1 2 3 Chemical Sensitivity(Required) 0 1 2 3 Infertility Problems(Required) 0 1 2 3 Depression(Required) 0 1 2 3 Sleep Disturbances(Required) 0 1 2 3 Irritability(Required) 0 1 2 3 Elevated Triglycerides(Required) 0 1 2 3 Cold Body Temperature(Required) 0 1 2 3 Sugar Cravings(Required) 0 1 2 3 Moody(Required) 0 1 2 3 Stress(Required) 0 1 2 3 Aches and Pains(Required) 0 1 2 3 Headaches(Required) 0 1 2 3 Perspiration(Required) 0 1 2 3 Anxiety(Required) 0 1 2 3 Tired Or Exhausted(Required) 0 1 2 3 Weight Loss Difficulty(Required) 0 1 2 3 Swelling Puffy Eyes Or Face(Required) 0 1 1 2 Rapid Heart Rate(Required) 0 1 2 3 Sweaty(Required) 0 1 2 3 Agitated(Required) 0 1 2 3 Hot Feelings(Required) 0 1 2 3 Weight Loss(Required) 0 1 2 3 Difficulty Concentrating(Required) 0 1 2 3 Nervousness(Required) 0 1 2 3 Allergies(Required) 0 1 2 3 Excessive Facial Hair(Required) 0 1 2 3 Dry And Brittle Hair(Required) 0 1 2 3 Dry Skin And Hair(Required) 0 1 2 3 Hoarseness(Required) 0 1 2 3 Slowed Reflexes(Required) 0 1 2 3 Constipation(Required) 0 1 2 3 Decreased Sweating(Required) 0 1 2 3 Mood Changes(Required) 0 1 2 3 Low Blood Pressure(Required) 0 1 2 3 Slow Pulse Rate(Required) 0 1 2 3 Cold Hands And Feet(Required) 0 1 2 3 Nails Brittle Or Breaking(Required) 0 1 2 3 Forgetful(Required) 0 1 2 3 Arthritis(Required) 0 1 2 3 Weight Gain(Required) 0 1 2 3 Elevated Cholesterol(Required) 0 1 2 3 Slow Ankle Reflex(Required) 0 1 2 3 Thinning Public Hair(Required) 0 1 2 3 This field is hidden when viewing the formTestosterone ResultThis field is hidden when viewing the formCortisol ResultThis field is hidden when viewing the formThyroid ResultHRT Monthly(Required) Price: Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and 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