Hormone Health Assessment

This assessment takes just 3-4 minutes to complete.

By completing this form, you confirm that the information provided is accurate to the best of your knowledge and that you are submitting it on your own behalf. The information you provide will be used exclusively to create a personalized treatment plan. All data collected is securely stored, encrypted, and remains confidential with Reboot Wellness. Your privacy and security are our top priorities.

Do you often feel tired or lack energy, even after a good night's sleep? *

Yes

Have you noticed persistent fatigue throughout the day? *

Yes

Do you experience brain fog or trouble concentrating? *

Yes

Have you felt less sharp or productive recently? *

Yes

Have you gained weight, especially around your belly, despite no significant change in diet or exercise? *

Yes

Do you find it harder to lose weight than before? *

Yes

Have you noticed a loss of muscle strength or difficulty building muscle? *

Yes

Do your workouts feel less effective, even with effort? *

Yes

Do you experience mood swings, increased irritability, or feelings of anxiety or sadness? *

Yes

Do you feel like you’ve lost your sense of well-being? *

Yes

Are you struggling with poor sleep, such as trouble falling asleep, staying asleep, or waking up feeling unrested? *

Yes

Has your sleep pattern significantly changed recently? *

Yes

Are you experiencing erectile dysfunction or a noticeable drop in your sex drive? *

Yes

Do you feel less motivated to tackle daily tasks or set and achieve goals? *

Yes

Have you felt less ambitious or driven lately? *

Yes

Have you experienced a significant drop in energy, strength, or libido as you've aged? *

Yes

Do you have persistent issues with belly fat or other signs of being overweight? *

Yes

Do you feel like your body isn’t responding to healthy diet and exercise the way it used to? *

Yes

First Name *

Last Name *

Email *

Date of birth *

Gender

male
female
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