EmailMeForm
**********FEMALE SYMPTOM SHEET (follow-up)********
****USE THIS FORM TO INDICATE ANY CHANGES IN YOUR SYMPTOMS****
LOCATION
SEEN
FWB
CV
PENSACOLA
TAMPA
COLORADO
OTHER STATE
NAME
First
Last
DATE
MM
/
DD
/
YYYY
PHONE
TEXT
###
-
###
-
####
EMAIL
D.O.B
MM
/
DD
/
YYYY
NAME OF PHYSICIAN
OR PRACTITIONER
ENTER THE NAME OF THE MD/DO OR PRACTITIONER
HOT FLASHES
NONE
MILD
MODERATE
SEVERE
EXTREME
IMPROVED
NIGHT SWEATS
NONE
MILD
MODERATE
SEVERE
EXTREME
IMPROVED
VAGINAL DRYNESS
NONE
MILD
MODERATE
SEVERE
EXTREME
IMPROVED
URINARY LEAKAGE
NONE
MILD
MODERATE
SEVERE
EXTREME
IMPROVED
FREQUENT UTI'S
NONE
MILD
MODERATE
SEVERE
EXTREME
IMPROVED
PAINFUL SWOLLEN BREASTS
NONE
MILD
MODERATE
SEVERE
EXTREME
IMPROVED
INSOMNIA
NONE
MILD
MODERATE
SEVERE
EXTREME
IMPROVED
MOOD SWINGS
NONE
MILD
MODERATE
SEVERE
EXTREME
IMPROVED
HEADACHES
NONE
MILD
MODERATE
SEVERE
EXTREME
IMPROVED
NERVE PAIN
NONE
MILD
MODERATE
SEVERE
EXTREME
IMPROVED
DEPRESSION
NONE
MILD
MODERATE
SEVERE
EXTREME
IMPROVED
LOW LIBIDO
NONE
MILD
MODERATE
SEVERE
EXTREME
IMPROVED
INABILITY TO ACHIEVE
ORGASM
NONE
MILD
MODERATE
SEVERE
EXTREME
IMPROVED
PAIN DURING SEX
NONE
MILD
MODERATE
SEVERE
EXTREME
IMPROVED
LOW ENERGY
NONE
MILD
MODERATE
SEVERE
EXTREME
IMPROVED
WEIGHT GAIN
NONE
MILD
MODERATE
SEVERE
EXTREME
IMPROVED
COLD HANDS AND FEET
NONE
MILD
MODERATE
SEVERE
EXTREME
IMPROVED
LOW BODY TEMPERATURE
NONE
MILD
MODERATE
SEVERE
EXTREME
IMPROVED
COMMENTS OTHER
ISSUES
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