Intake form

Name *

Email address *

What symptoms are you currently experiencing?

Please select at least one option.

Hot flashes

Night sweats

Mood changes

Sleep disturbances

Weight gain

Joint pain

Memory issues

Have you previously received any hormonal treatments?

If yes, please specify the type of hormonal treatment you received.

Are you currently taking any non-hormonal treatments or supplements?

Please select at least one option.

Lifestyle changes

Vitamins

Herbal supplements

Other therapies

None

What is your age range?

Do you have any existing medical conditions?

Please select at least one option.

Diabetes

Hypertension

Thyroid issues

Heart disease

Cancer

None

How would you rate your current quality of life related to menopause?

What are your primary goals for seeking menopause care?

Please select at least one option.

Symptom relief

Education about menopause

Support for lifestyle changes

Hormone therapy consideration

Additional questions or comments

Evolv