Are You a Candidate for Our Cosmetic Procedure

Symptoms

(Please Pick One for Each Symptom)

Decline in general well being*

Never
Mild
Moderate
Severe

Joint pain/muscle ache*

Never
Mild
Moderate
Severe

Excessive sweating*

Never
Mild
Moderate
Severe

Sleep problems*

Never
Mild
Moderate
Severe

Increased need for sleep*

Never
Mild
Moderate
Severe

Irritability*

Never
Mild
Moderate
Severe

Nervousness*

Never
Mild
Moderate
Severe

Anxiety*

Never
Mild
Moderate
Severe

Depressed mood*

Never
Mild
Moderate
Severe

Exhaustion/lacking vitality*

Never
Mild
Moderate
Severe

Declining Mental Ability/Focus/>Concentration*

Never
Mild
Moderate
Severe

Feeling you have passed your peak*

Never
Mild
Moderate
Severe

Feeling burned out/hit rock bottom*

Never
Mild
Moderate
Severe

Decreased muscle strength*

Never
Mild
Moderate
Severe

Weight Gain/Belly Fat/Inability to Lose Weight*

Never
Mild
Moderate
Severe

Breast Development*

Never
Mild
Moderate
Severe

Shrinking Testicles*

Never
Mild
Moderate
Severe

Rapid Hair Loss*

Never
Mild
Moderate
Severe

Decrease in beard growth*

Never
Mild
Moderate
Severe

New Migraine Headaches*

Never
Mild
Moderate
Severe

Decreased desire/libido*

Never
Mild
Moderate
Severe

Family History

Heart Disease*

NO
YES

Diabetes*

NO
YES

Osteoporosis*

NO
YES

Alzheimer's Disease*

NO
YES

Name*

First Last

Phone*

Email*

Cosmetic Surgery

Are You a Candidate?

Women

Men

Health Assessment for Women

Symptoms

Family History

Health Assessment for Men

Symptoms

Family History