Download Wellness Screening Wellness Screening First Name Last Name Date of Birth Weight 1. Decline in general well being Never Mild Moderate Severe 2. Joint pain/muscle ache Never Mild Moderate Severe 3. Excessive sweating/ hot flashes Never Mild Moderate Severe 4. Sleep problems Never Mild Moderate Severe 5. Irritability Never Mild Moderate Severe 6. Nervousness Never Mild Moderate Severe 7. Anxiety Never Mild Moderate Severe 8. Depressed mood Never Mild Moderate Severe 9. Exhaustion/lacking vitality Never Mild Moderate Severe 10. Declining mental ability/focus/concentration Never Mild Moderate Severe 11. Decreased muscle strength Never Mild Moderate Severe 12. Weight gain/ increased belly fat / inability to lose weight Never Mild Moderate Severe 13. Breast tenderness Never Mild Moderate Severe 14. Rapid hair loss Never Mild Moderate Severe 15. Migraine headaches Never Mild Moderate Severe 16. Decreased sexual libido/desire Never Mild Moderate Severe 17. Decreased ability to perform sexually/climax Never Mild Moderate Severe 18. Dry skin Never Mild Moderate Severe 19. Cold all the time Never Mild Moderate Severe 20. Constipation Never Mild Moderate Severe 21. White spots on nails Never Mild Moderate Severe 22. Bruise easily Never Mild Moderate Severe 23. Loud noises bother you Never Mild Moderate Severe 24. Frequent heartburn Never Mild Moderate Severe 25. Wake up tired Never Mild Moderate SevereTotal 0-40: Fairly healthy; 40-60: Some hormonal imbalance is likely; 60 or more: Deficiency is probableTop 5 Main Concerns: Please elaborate on the symptoms and frequency that you experience your primary concerns. What kinds of alternate therapies have you tried? Allergies: Medications: Date of last menstrual period: Medical History/Chronic Illness: Are you on birth control? Yes No Hysterectomy? Yes No Do you still have ovaries? Yes No Are you using hormone therapy now? Yes No History of breast cancer? Yes No Fibrocystic breast disease? Yes No Uterine ablation? Yes No Metabolic disease? Yes No Testicular cancer? Yes No Diabetes? Yes No Colon cancer? Yes No Active Liver disease? Yes No Renal disease? Yes No Acne? Yes No Prostate cancer? Yes NoI hereby consent to Dr Chang or his office staff to draw my blood for testing. I understand that blood draw may lead to bruising, swelling, discomfort, bleeding at the site of blood draw. Results from my lab work will be reviewed over the phone or may be left on voicemail. Phone Number: Preferred Email: Date: Patient Name: Patient Signature: ❌19500 Sandridge Way, Suite 350 • Lansdowne, VA 20176 • Phone 703-729-5553 • Fax 703-729-1694 • www.gotobeauty.com Submit
