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Wellness Screening

Name
MM slash DD slash YYYY
1. Decline in general well being
2. Joint pain/muscle ache
3. Excessive sweating/ hot flashes
4. Sleep problems
5. Irritability
6. Nervousness
7. Anxiety
8. Depressed mood
9. Exhaustion/lacking vitality
10. Declining mental ability/focus/concentration
11. Decreased muscle strength
12. Weight gain/ increased belly fat / inability to lose weight
13. Breast tenderness
14. Rapid hair loss
15. Migraine headaches
16. Decreased sexual libido/desire
17. Decreased ability to perform sexually/climax
18. Dry skin
19. Cold all the time
20. Constipation
21. White spots on nails
22. Bruise easily
23. Loud noises bother you
24. Frequent heartburn
25. Wake up tired

Total

0-40: Fairly healthy; 40-60: Some hormonal imbalance is likely; 60 or more: Deficiency is probable.

Top 5 Main Concerns

MM slash DD slash YYYY
Are you on birth control?
Hysterectomy?
Do you still have ovaries?
Are you using hormone therapy now?
History of breast cancer?
Fibrocystic breast disease?
Uterine ablation?
Metabolic disease?
Testicular cancer?
Diabetes?
Colon cancer?
Active Liver disease?
Renal disease?
Acne?
Prostate cancer?

I 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.
MM slash DD slash YYYY

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