Female Assessment Request | Revita Anti-Aging®

Name*

First Last

Email

Phone

Overall how would you subjectively rate your health? Some general examples are listed above. We only need an overall rating you will provide us detail in the next section. Thank You*

Please List 1 - 3 Health Goals

Health Goal 1

Health Goal 2

Health Goal 3

Symptom Scoring Form

The following score sheet will help the doctor and you to determine whether hormone testing is needed and which tests to order. Each category is divided into hormone deficiency and excess as each has a different subset of symptoms. Please score the symptoms which apply to you.

Scoring Scale: 0 (none), 1(mild), 2 (moderate), or 3 (severe). * A cumulative score of 10 (ten) or higher within any single category (deficiency and excess combined) suggests testing 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

Administrative Scores

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

Please List 1 - 3 Health Goals

Symptom Scoring Form

Administrative Scores

Revita Medical – The Fountains