BHRT Survey
Depressive Mood
*
Never
Mild
Moderate
Severe
Memory Loss
*
Never
Mild
Moderate
Severe
Mental Confusion (feeling foggy)
*
Never
Mild
Moderate
Severe
Decreased Sex Drive
*
Never
Mild
Moderate
Severe
Sleep Problems
*
Never
Mild
Moderate
Severe
Mood Changes / Irritability
*
Never
Mild
Moderate
Severe
Tension
*
Never
Mild
Moderate
Severe
Migraines / Severe Headaches
*
Never
Mild
Moderate
Severe
Difficulty with Sexually Climaxing
*
Never
Mild
Moderate
Severe
Bloating
*
Never
Mild
Moderate
Severe
Weight Gain
*
Never
Mild
Moderate
Severe
Breast Tenderness
*
Never
Mild
Moderate
Severe
Vaginal Dryness
*
Never
Mild
Moderate
Severe
Hot Flashes
*
Never
Mild
Moderate
Severe
Night Sweats
*
Never
Mild
Moderate
Severe
Dry and Wrinkled Skin
*
Never
Mild
Moderate
Severe
Hair Loss
*
Never
Mild
Moderate
Severe
Swelling All Over Body
*
Never
Mild
Moderate
Severe
Joint Pain
*
Never
Mild
Moderate
Severe
Name
*
First Name
Last Name
Email
*
example@example.com
Age
*
Phone Number
-
Area Code
Phone Number
Please verify that you are human
*
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