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BHRT Checklist for Women Privacy Policy 50% Complete (success) First Name * Last Name * Email * Phone * What is the best way to contact you? Email Phone Text What is the best time to reach you? Street Address City State/Province/Region Zip/Postal Code * Country Please select oneAfghanistan≈land IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamas (the)BahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean Territory (the)Brunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman Islands (the)Central African Republic (the)ChadChileChinaChristmas IslandCocos (Keeling) Islands (the)ColombiaComoros (the)Congo (the Democratic Republic of the)Congo (the)Cook Islands (the)Costa RicaCÙte d’IvoireCroatiaCubaCuraÁaoCyprusCzech Republic (the)DenmarkDjiboutiDominicaDominican Republic (the)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (the) [Malvinas]Faroe Islands (the)FijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern Territories (the)GabonGambia (the)GeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (the)HondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea (the Democratic People’s Republic of)Korea (the Republic of)KuwaitKyrgyzstanLao People’s Democratic Republic (the)LatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia (the former Yugoslav Republic of)MadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall Islands (the)MartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Midway IslandsMoldova (the Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlands (the)New CaledoniaNew ZealandNicaraguaNiger (the)NigeriaNiueNorfolk IslandNorthern Mariana Islands (the)NorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippines (the)PitcairnPolandPortugalPuerto RicoQatarRÈunionRomaniaRussian Federation (the)RwandaSaint BarthÈlemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSouthern RhodesiaSpainSri LankaSudan (the)SurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan (Province of China)TajikistanTanzania, United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos Islands (the)TuvaluUgandaUkraineUnited Arab Emirates (the)United KingdomUnited StatesUnited States Minor Outlying Islands (the)Upper VoltaUruguayUzbekistanVanuatuVenezuela (Bolivarian Republic of)Viet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Additional Info How did you hear about us? Search Engine Radio Yellow Pages Twitter Facebook Instagram TV Physician Friend / Family Member Other Other 100% Complete (success) Which of the following symptoms apply at this time? Please check EACH symptom. For symptoms that do not apply, please mark NONE. Hot flashes, sweating (episodes of sweating) None Mild Moderate Severe Extremely Severe Heart discomfort (unusual awareness of heart beat, heart skipping, heart racing, tightness) None Mild Moderate Severe Extremely Severe Sleep problems (difficulty in falling asleep difficulty in sleeping through, waking up early and feeling tired, poor sleep, sleeplessness) None Mild Moderate Severe Extremely Severe Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings) None Mild Moderate Severe Extremely Severe Irritability (feeling nervous, inner tension, feeling aggressive) None Mild Moderate Severe Extremely Severe Anxiety (inner restlessness, feeling panicky) None Mild Moderate Severe Extremely Severe Physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness) None Mild Moderate Severe Extremely Severe Sexual problems (change in sexual desire, in sexual activity and satisfaction) None Mild Moderate Severe Extremely Severe Bladder problems (difficulty in urinating, increased need to urinate, bladder incontinence) None Mild Moderate Severe Extremely Severe Dryness of vagina, sensation of dryness or burning in the vagina, difficulty with sexual intercourse None Mild Moderate Severe Extremely Severe Joint and muscular discomfort (pain in the joints, rheumatoid complaints) None Mild Moderate Severe Extremely Severe Please share any additional comments about your symptoms you would like to address.
