• This form will be emailed to Dr Haffejie

    Please answer all questions.
  •  -
  • Estrogen Sensitivity

    How did you feel when you were 35?
  • KEY:

    3 = Predominantly first option

    2 = In between, average 

    1 = Predominantly second option

  • How do you feel now?

    KEY: 3 = Severe | 2 = Moderate | 1 = Mild | 0 = Not at all/not applicable
  • How do you feel now?

    KEY: 3 = Severe | 2 = Moderate | 1 = Mild | 0 = Not at all/not applicable
  •  
  • Should be Empty: