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Have you experienced any of the following symptoms recently? Please circle the number that best describes your experience.
Food Cravings
Yes
No
Fatigue
Yes
No
Hot Flashes
Yes
No
Night Sweats
Yes
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Weight Gain
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No
Dry Hair
Yes
No
Dry Skin
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Hair Loss
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Breast Tenderness
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No
Fibrocystic Breasts
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Heart Palpitations
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Bloating
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Bladder Symptoms
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Frequent UTI or Incontinence
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Painful Intercourse
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Arthritis/Joint Pain
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Fluid Retention
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Foggy Brain/Fuzzy Thinking
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Headaches
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No
Anxiety
Yes
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Depression
Yes
No
Irritability
Yes
No
Inability to Concentrate
Yes
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Mood Swings
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PMS
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Nervousness
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Poor Sleep
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Decreased Sex Drive
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Harder to Reach Climax
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Δ
Dr. Novlet Davis,
"Dr. D"
Licensed Physician & Autism Specialist
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Steven N. Hannant
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“Dr. Steve”
PsyD, MSCP, Clinical Psychologist
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Regan L. Hannant
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