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Quality Of Life Questionnaire

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Hormone Deficiency Test: Please fill out the confidential quality of hormone health Questionnaire below and please upon completion please call our hormone clinic to verify you completed it at 1-800-996-9664. If we are unavailable to answer the phone at the time you call, please leave a detailed message and we will call you back within 24 hours.

This questionnaire will help us to learn more about the age related symptoms of hormone deficiency and decline you may be experiencing.

Full Name (*Required)	Date Of Birth (*Required)
Day Phone (*Required)	Evening Phone (*Required)
Email (*Required)	Confirm Email (*Required)
US State (*Required)

Contact Time

(*Required)

I Am At Least 30 Years Old, And My Age Is

(*Required)

Your Gender (Choose One) Male Female (*Required)

Q1) I Have to struggle to finish task Yes No (*Required)	Q2) I feel a strong need to sleep during the day Yes No (*Required)	Q3) I often feel lonely even when I am with other people Yes No (*Required)
Q4) I have to read things several times before they sink in Yes No (*Required)	Q5) It is difficult for me to make friends Yes No (*Required)	Q6) It takes a lot of effort for me to do simple task Yes No (*Required)

Q7) I have a difficult time controlling my emotions Yes No (*Required)	Q8) I often lose track of what I want to say Yes No (*Required)	Q9) I lack confidence Yes No (*Required)
Q10) I have to push myself to do things Yes No (*Required)	Q11) I feel as if i let people down Yes No (*Required)	Q12) I find it hard to mix with people Yes No (*Required)

Q13) I feel worn out even when I have done nothing Yes No (*Required)	Q14) There are times when I feel very depressed Yes No (*Required)	Q15) I avoid responsibility when possible Yes No (*Required)
Q16) I feel as if i am a burden to people Yes No (*Required)	Q17) I often forget what people have said to me Yes No (*Required)	Q18) I find it difficult to plan ahead Yes No (*Required)

Q19) I am easily irritated by other people Yes No (*Required)	Q20) I often feel too tired to do the things I ought to do Yes No (*Required)	Q21) I have to force myself to do all of the things that need doing Yes No (*Required)
Q22) I often have to force myself to stay awake Yes No (*Required)	Q23) My memory lets me down Yes No (*Required)

Comments

Please explain any 'yes' answer to question on left

Please list any medications you are taking or allergic to

Enter Above Code:

(*Required)

CALL: 1-800-996-9664
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Conscious Evolution Institute of Physicians Rejuvenation, 5608 PGA Boulevard #208, Palm Beach Gardens, FL 33418.

Disclaimer: The board-certified American physician specialists at our reputable medical clinic do not provide prescriptions and HRT treatments unless there is a clinical necessity for the patient at the time of the assessment. Clinically based hormone deficiency is determined by blood testing, physical exam, related symptoms evaluation, medical history documentation, and doctor-patient consultation. These statements presented here at our website have not been evaluated by the FDA.