Hormone Evaluation – Please fill out the information below and click “Submit”

Once the form is submitted you will receive an email with instructions for contact

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Do you have trouble staying asleep?

YesNo

Do you grind your teeth or clench your jaw at night?

YesNo

Any anger issues including road rage?

YesNo

Do you have headaches?

YesNo

Any history of IBS?

YesNo

Have you ever had significant menstrual cramps or PMS?

YesNo

Any history of fibroids, or endometriosis, or ovarian cysts, or fibrocystic disease?

YesNo

Do you have trouble holding urine if you cough, sneeze or laugh?

YesNo

Do you wake up with low back pain or pain along the side of your hip?

YesNo

Do you often feel sluggish?

YesNo

Any problem with dry skin; does the skin on the back of your heels crack?

YesNo

Do your nails chip or peel easily or are they soft?

YesNo

Do you have a low body temperature?

YesNo

Do you get especially sleepy or crave sweets between 3 and 4PM?

YesNo

On car trips, do you have trouble keeping your eyes open?

YesNo

Do you have a weight problem?

YesNo

Is your excess fat mainly around the middle?

YesNo

Do you have trouble focusing?

YesNo

Do you have a problem with brain fog or memory issues?

YesNo

How did you hear about
Michael E. Platt, MD?

List of medications:

Additional information or questions