320 KINGWOOD EXECUTIVE DR. SUITE D KINGWOOD, TX 77339
(281) 666-9211
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BioTE Assessment Quiz
Name
*
Phone
*
Email
*
Fatigue
*
Never
Mild
Moderate
Severe
Mood Changes: Irritability, Anxiety, Nervousness / Depression
*
Never
Mild
Moderate
Severe
Hot Flashes: Night Sweats
*
Never
Mild
Moderate
Severe
Weight Gain: Bloating, Excessive Belly Fat / Inability to Lose Weight
*
Never
Mild
Moderate
Severe
Decreased Sex Drive: Vaginal Dryness
*
Never
Mild
Moderate
Severe
Sleep Problems: Can’t Stay Asleep and/or Can’t Fall Asleep
*
Never
Mild
Moderate
Severe
Cold Hands & Feet / Always Cold
*
Never
Mild
Moderate
Severe
Hair loss / Breakage
*
Never
Mild
Moderate
Severe
Dry Wrinkled Skin
*
Never
Mild
Moderate
Severe
FAMILY HISTORY / Heart Disease
*
Yes
No
FAMILY HISTORY / Diabetics
*
Yes
No
FAMILY HISTORY / Osteoporosis
*
Yes
No
FAMILY HISTORY / Alzheimer’s Disease
*
Yes
No
FAMILY HISTORY/ Breast Cancer
*
Yes
No
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