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Name
*
First
Last
Email
*
Phone Number
*
Overall how would you rate your overall general health from 1 to 10? Don’t worry we will get more specific as the assessment continues.
*
1
2
3
4
5
6
7
8
9
10
Please list your top 3 Health and Wellness Goals, e.g. to lose weight, to gain energy, to increase libido, etc.
Health Goal 1
Health Goal 2
Health Goal 3
Please rate the following symptoms from 0 (none) to 3 (severe). Each category will rate a possible hormone imbalance and will help us determine which tests may be beneficial.
Low Libido
0
1
2
3
Depressed
0
1
2
3
Decreased Muscle Mass
0
1
2
3
Sleep Disturbances
0
1
2
3
Fatigue
0
1
2
3
Bone Loss
0
1
2
3
Memory Lapses
0
1
2
3
Thinning Skin
0
1
2
3
Incontinence
0
1
2
3
Fibromyalgia
0
1
2
3
Heart Palpitations
0
1
2
3
Excessive Facial Hair
0
1
2
3
Oily Skin
0
1
2
3
Excessive Body Hair
0
1
2
3
Hair Loss (Scalp)
0
1
2
3
Increased Acne
0
1
2
3
Irritable
0
1
2
3
Breast Cancer/ Person or Family
0
1
2
3
Elevated Triglycerides
0
1
2
3
Chemical Sensitivity
0
1
2
3
Cold Body Temperature
0
1
2
3
Sugar Cravings
0
1
2
3
Irritable
0
1
2
3
Allergies
0
1
2
3
Arthritis
0
1
2
3
Stress
0
1
2
3
Ache / Pains
0
1
2
3
Headaches
0
1
2
3
Weight Gain / Waist
0
1
2
3
Increased Facial Hair
0
1
2
3
Anxious
0
1
2
3
Increased Body Hair
0
1
2
3
Tired or Exhausted
0
1
2
3
Nails Breaking / Brittle
0
1
2
3
Cold Hands and Feet
0
1
2
3
Dry and Brittle Hair
0
1
2
3
Dry Skin / Hair
0
1
2
3
Hoarseness
0
1
2
3
Slowed Reflexes
0
1
2
3
Infertility Problems
0
1
2
3
Constipation
0
1
2
3
Decreased Sweating
0
1
2
3
Mood Changes
0
1
2
3
Swelling / Puffy (Eyes / Face)
0
1
2
3
Low Blood Pressure
0
1
2
3
Slow Pulse Rate
0
1
2
3
Rapid Heart Rate
0
1
2
3
Sweaty
0
1
2
3
Agitated
0
1
2
3
Hot Feelings
0
1
2
3
Weight Loss
0
1
2
3
Difficult to Concentrate / Loss of Focus
0
1
2
3
Forgetful
0
1
2
3
Hair Loss
0
1
2
3
High Cholesterol
0
1
2
3
Nervousness
0
1
2
3
Slow Ankle Reflex
0
1
2
3
Weight Gain
0
1
2
3
Weight Loss Difficulty
0
1
2
3
Thinning Pubic Hair
0
1
2
3
Bleeding Changes
0
1
2
3
Breast Swelling / Tenderness
0
1
2
3
Candida Infections
0
1
2
3
Cramps
0
1
2
3
Endometriosis
0
1
2
3
Fibrocystic Breasts
0
1
2
3
Fibroids
0
1
2
3
Fluid Retention
0
1
2
3
Foggy Thinking
0
1
2
3
Hot Flashes
0
1
2
3
Hypothyroid
0
1
2
3
Irregular Periods
0
1
2
3
Mood Swings (OMS)
0
1
2
3
Night Sweats
0
1
2
3
Sleepiness
0
1
2
3
Stressed Easily
0
1
2
3
Tearful
0
1
2
3
Tender Breasts
0
1
2
3
Uterine Fibroids
0
1
2
3
Water Retention
0
1
2
3
Weight Gain: Hips
0
1
2
3
Vaginal Dryness
0
1
2
3
Heavy Periods
0
1
2
3
Break Thru Bleeding
0
1
2
3
The following information is a guideline only but shows the likelihood that you are imbalanced in the following hormone categories. We will use this as the basis of a free 30-minute assessment with a trained medical assessment to determine if we may be able to help you.
Androgen Deficiency Score
Androgen Excess Score
Cortisol Deficiency Score
Cortisol Excess Score
Thyroid Deficiency Score
Thyroid Excess Score
Estrogen / Estradiol Deficiency Score
Estrogen / Estradiol Excess Score
Progesterone Deficiency Score
Progesterone Excess Score
Close Menu
Home
Revita’s Treatments
Hormone Replacement Therapy for Men
Hormone Replacement Therapy for Women
PCOS Treatment For Women
Weight Management
Individualized Fitness & Nutrition Programs
Learn More
Articles
Cost of Hormone Replacement Therapy
FAQ: Question and Answer
About the Revita Medical Center
Testimonials
Contact Us
