Female Hormone Assessment

Instructions: This comprehensive assessment is designed to help determine if Bioidentical Hormone Replacement Therapy (BHRT) may benefit you. Please answer each question honestly based on your experiences over the past 6 months.

Dr. Ibrahim’s extensive experience in both men’s and women’s health, combined with his training in Anti-Aging Medicine, ensures you receive expert evaluation and personalized care.

Once finished, you can choose to have a copy of the assessment emailed to you in pdf format.

Confidentiality: All information provided is strictly confidential and will only be shared with your healthcare team at Biltmore Restorative Medicine.

Name(You may use your first name only or a pseudonym)

Age

Phone(Optional – provide if you would like to be contacted to discuss a consultation)

Email Address(Optional – provide if you would like to receive a copy of this assessment by email)

Preferred Method of ContactNonePhoneEmailText

How did you hear about us?Internet SearchAI RecommendedSocial MediaReferralAdvertisementOther

Menstrual & Reproductive History

Current menstrual statusRegular periodsIrregular periodsPerimenopauseMenopausePost-menopause

Age at first period

Age when periods stopped (if applicable):

How many years ago was your last menstrual period? (if applicable)

Are you currently using hormonal contraceptives?YesNo

What type are you using?0 / 100

Number of pregnancies

Number of live births

Number of miscarriages

Age at menopause (if applicable)

Cause of MenopauseNaturalSurgical

Have you had a hysterectomy?YesNo

Ovaries removed?YesNo

Do you have an IUD?YesNo

What type or name?0 / 100

What is your means of birth control, if applicable?0 / 200

Current Symptoms Assessment

Rate each symptom on a scale of 0-5 (0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Often, 4 = Very Often, 5 = Always)

Menopausal/Hormonal Symptoms

Hot flashes *012345

Night Sweats *012345

Cold hands or feet *012345

Irregular or heavy periods *012345

Vaginal dryness or discomfort *012345

Painful intercourse *012345

Energy & Physical Symptoms

Fatigue or low energy *012345

Weight gain (especially midsection) *012345

Loss of muscle tone *012345

Joint aches and stiffness *012345

Headaches or migraines *012345

Bloating or water retention *012345

Skin, Hair & Appearance

Dry skin or thinning skin *012345

Hair loss or thinning hair *012345

Brittle or weak nails *012345

Unwanted facial hair growth *012345

Loss of skin elasticity *012345

Sexual Health & Libido

Decreased interest in sex *012345

Difficulty reaching orgasm *012345

Reduced intensity of orgasms *012345

Overall sexual dissatisfaction *012345

Urinary incontinence (stress or urge) *012345

Mental & Emotional Health

Mood swings or irritability *012345

Anxiety or panic attacks *012345

Depression or feeling "blue" *012345

Memory problems or "brain fog" *012345

Difficulty concentrating *012345

Feeling overwhelmed easily *012345

Sleep & Energy Patterns

Difficulty falling asleep *012345

Frequent nighttime awakening *012345

Early morning awakening *012345

Feeling unrefreshed upon waking *012345

Afternoon energy crashes *012345

Medical History

Current Health Status

Have you been diagnosed with any of the following? (Check all that apply)

CheckboxDiabetesHigh Blood PressureHeart DiseaseThyroid ProblemsOsteoporosisBreast CancerEndometrial CancerOvarian CancerBlood ClotsStrokeDepression/AnxietyFibromyalgiaAutoimmune DiseaseSleep Apnea

Other0 / 200

Current Medications/Supplements

Drug allergies

Previous Hormone Experience

Have you ever used hormone replacement therapy?YesNo

What type and duration?0 / 200

Previous hormone testing:YesNo

When and results?0 / 200

Have you used birth control pills?YesNo

Duration and any issues0 / 200

Family History

Mother's health history0 / 300

Sister's health history0 / 300

Family history of:Breast CancerOvarian CancerEndometrial CancerOsteoporosisHeart DiseaseStrokeBlood ClotsEarly menopause

Lifestyle Factors

Exercise FrequencyDaily3 to 4 times per week1 to 2 times per weekRarelyNever

Exercise TypeCardioWeight trainingYogaPilatesOther

Stress Level from 1 to 10 (10 being extremely stressed)

How do you manage stress0 / 300

Alcohol consumption per weekNeverRarely1 drink1 to 3 drinks4 drinks or more

Caffeine IntakeRarelyOften

SmokingCurrent smokerFormer smokerNever smoked

Average hours of sleep per night

Sleep quality from 1 to 10 (10 being great)

Diet typeStandardLow carbMediterraneanVegetarianVeganOther

Specific Goals and Expectations

What are your primary goals with hormone therapy? (Check all that apply)Eliminate hot flashes and night sweatsImprove energy and reduce fatigueEnhance sexual desire and functionImprove mood and reduce anxiety/depressionBetter sleep qualityWeight managementPrevent bone lossImprove skin and hairReduce “brain fog” and improve memoryOverall anti-aging benefits

Other0 / 100

How significantly are your symptoms impacting your quality of life?MinimallyModeratelySignificantlySeverely

What would success look like for you?0 / 300

Are you interested in learning about: (Dr. Ibrahim's specialties)O-Shot for sexual wellness and urinary healthAesthetic treatmentsWeight loss programsOther regenerative therapies

Additional Screening Questions

Do you have concerns about hormone therapy based on media reports?YesNo

Please explain0 / 200

Are you currently working with other healthcare providers for these symptoms?YesNo

Please specify0 / 200

Have you tried other treatments for these symptoms?YesNo

What treatments and results?0 / 200

Any additional symptoms or concerns

Any questions for Dr. Ibrahim

Are you ready to calculate your score?YesNo

Calculation 1

Mild Symptoms Detected

Mild Symptoms Detected

Thank you for completing the Biltmore Restorative Medicine Female Hormone Assessment.

Based on your responses, your total symptom score is {calculation-1}/165, which falls into the Mild Symptoms range.

What This Means:

Your current symptoms suggest that you may be experiencing some early hormonal changes, but they are not yet significantly impacting your daily quality of life. Many women in this range can achieve meaningful improvements through lifestyle optimization and preventive measures.

Recommended Next Steps:

Lifestyle Optimization Focus:

Nutrition: Consider a hormone-supportive diet rich in healthy fats, lean proteins, and cruciferous vegetables
Exercise: Regular physical activity (150 minutes weekly) helps maintain hormonal balance
Stress Management: Chronic stress disrupts hormone production… explore meditation, yoga, or other stress-reduction techniques
Sleep Hygiene: Prioritize 7-9 hours of quality sleep nightly to support hormone regulation
Limit Toxins: Reduce exposure to endocrine disruptors in plastics, personal care products, and processed foods

Monitor Your Symptoms: Keep track of any changes in your symptoms over the coming months. Early intervention is always easier than waiting until symptoms become severe.
Educational Consultation (Optional): While you may not need immediate hormone therapy, an educational consultation with Dr. Ibrahim can help you:

Understand your hormone health baseline
Learn preventive strategies
Establish a relationship for future needs
Get personalized lifestyle recommendations

When to Take Action:

Consider scheduling a consultation if:

Your symptoms worsen over the next 3-6 months
You notice new or different symptoms
Lifestyle modifications don’t provide relief
You’d like baseline hormone testing for future comparison
You have questions about hormone health and aging

Educational Resources:

We recommend exploring these topics to support your hormone health:

Understanding perimenopause and hormonal transitions
Natural approaches to hormone balance
Preventive strategies for long-term wellness
When hormone therapy becomes appropriate

Ready to Learn More?

Schedule an educational consultation to discuss your hormone health and prevention strategies:

Call: (864) 202-6583 Email: info@HormoneTherapyGreenvilleSC.com

Remember: This assessment is for educational purposes only and does not constitute medical advice. Please consult with a qualified healthcare provider for personalized recommendations.

HIPAA Disclaimer

Moderate Symptoms Detected

Moderate Symptoms Detected

Thank you for completing the Biltmore Restorative Medicine Female Hormone Assessment.

Based on your responses, your total symptom score is {calculation-1}/165, which falls into the Moderate Symptoms range.

What This Means:

Your symptoms suggest a meaningful hormonal imbalance that is affecting your quality of life. You are likely experiencing the effects of perimenopause, menopause, or other hormonal changes that could benefit from professional evaluation and treatment.

You are a strong candidate for Bioidentical Hormone Replacement Therapy (BHRT).

Women in your symptom range typically see significant improvements with properly balanced hormone therapy, often reporting they “feel like themselves again” within weeks to months of starting treatment.

Why This Matters:

Moderate symptoms don’t just affect how you feel… they can impact:

Your relationships and intimacy
Work performance and productivity
Mental clarity and decision-making
Physical health and fitness
Overall enjoyment of life
Long-term health risks (bone density, cardiovascular health, cognitive function)

The good news: These symptoms are treatable, and you don’t have to just “live with it.”

Recommended Next Steps:

Schedule a Consultation with Dr. Ibrahim (Highly Recommended)

Dr. George K. Ibrahim brings over 30 years of experience as a urologist and fellowship training in Anti-Aging Medicine. As the only certified Fellow of the American Academy of Anti-Aging Medicine in Western North Carolina, he specializes in helping women just like you restore hormonal balance and vitality.

Your consultation will include:

Comprehensive review of your symptoms and health history
Discussion of your goals and concerns
Evaluation of treatment candidacy
Overview of bioidentical hormone therapy options
Personalized treatment recommendations
Cost and timeline discussion

Comprehensive Hormone Testing

We recommend laboratory testing to identify specific hormonal imbalances:

Estradiol (E2), Progesterone, Testosterone
Thyroid panel (TSH, Free T3, Free T4)
FSH and LH
DHEA-S, Vitamin D, B12
Complete metabolic panel
Additional tests as indicated by your symptoms

Treatment Options to Discuss:

Based on your assessment, you may benefit from:

Bioidentical Hormone Pellet Implants (3-4 month duration, steady hormone levels)
Topical Hormone Creams (customized formulations)
Peptide Therapy (complementary cellular support)
O-Shot (if experiencing sexual wellness or urinary concerns)
Lifestyle and Nutritional Optimization

What to Expect:

Most women with moderate symptoms experience:

Initial improvements within 2-4 weeks
Significant relief of symptoms within 2-3 months
Continued optimization over 6 months
Restored energy, mood, and quality of life

Real Patient Experiences:

“I have improved my muscle mass and dropped down four notches on my belt since my first visit!” – Jill H.

“I’m a 56-year-old woman… My orgasms are easier to achieve and last longer. I highly recommend Dr. Ibrahim and the staff. They are professional and knowledgeable.” – O-Shot Patient

Take the Next Step Toward Feeling Like Yourself Again:

Special Note: Consultations are personalized and confidential. Dr. Ibrahim takes time to understand your unique situation and develop a treatment plan tailored specifically to your needs.

Call: (864) 202-6583 Email: info@HormoneTherapyGreenvilleSC.com

Remember: This assessment is for educational purposes only and does not constitute medical advice. Please consult with a qualified healthcare provider for personalized recommendations.

HIPAA Disclaimer

Significant Symptoms Detected

Significant Symptoms Detected

Thank you for completing the Biltmore Restorative Medicine Female Hormone Assessment.

Based on your responses, your total symptom score is {calculation-1}/165, which falls into the Significant Symptoms range.

What This Means:

Your symptoms indicate a substantial hormonal imbalance that is significantly impacting your quality of life across multiple areas. You are experiencing what many women describe as feeling “not like themselves” or “going through life in survival mode.”

You are an excellent candidate for comprehensive hormone optimization.

The Impact on Your Life:

With significant symptoms, you’re likely experiencing challenges in:

Daily Energy: Struggling to get through the day without exhaustion
Emotional Wellbeing: Mood swings, anxiety, or depression affecting relationships
Physical Health: Weight gain, loss of muscle tone, aches and pains
Sleep Quality: Poor sleep affecting everything else
Intimacy: Changes in libido and sexual satisfaction
Mental Clarity: “Brain fog” affecting work and daily tasks
Overall Quality of Life: Not enjoying activities you used to love

You deserve better… and relief is possible.

Why Immediate Action Matters:

Prolonged hormonal imbalance at this level can affect:

Bone density (increased osteoporosis risk)
Cardiovascular health
Cognitive function and memory
Metabolic health and weight
Immune system function
Overall aging process

The sooner you address these imbalances, the better your long-term health outcomes.

Immediate Recommended Actions:

PRIORITY CONSULTATION with Dr. Ibrahim

We strongly recommend scheduling your consultation within the next 1-2 weeks. Don’t wait—you’ve already been suffering long enough.

Why Dr. Ibrahim?

30+ years of experience treating hormonal issues in women
Urologist with deep understanding of women’s physiology
Fellowship training in Anti-Aging and Regenerative Medicine
Only certified Fellow of American Academy of Anti-Aging Medicine in Western NC
Member of North American Menopause Society
Advisory Board Member, The Menopause Association
Proven track record helping women restore their vitality

Comprehensive Evaluation Process:

Your consultation will be thorough and personalized:

Detailed Medical Review: Understanding your complete health picture
Symptom Analysis: Identifying all contributing factors
Laboratory Testing: Complete hormone panel plus metabolic markers
Treatment Planning: Customized protocol for your specific needs
Goal Setting: What does success look like for you?
Timeline Discussion: When can you expect to feel better?

Advanced Treatment Options:

At your symptom level, we may recommend:

Bioidentical Hormone Pellet Implants:

Steady, consistent hormone levels for 3-4 months
No daily pills or creams to remember
Proven most effective for significant symptoms
Most similar to your body’s natural hormone production

Comprehensive Protocol May Include:

Customized hormone therapy (estrogen, progesterone, testosterone as needed)
Peptide therapy for enhanced cellular function
O-Shot if experiencing sexual wellness or urinary concerns
Thyroid optimization if indicated
Nutritional support and supplementation
Lifestyle optimization strategies

What You Can Expect:

Women with significant symptoms typically experience:

Weeks 1-2:

Initial subtle improvements in sleep and energy
Reduction in hot flashes and night sweats
Beginning of mood stabilization

Weeks 3-8:

Noticeable energy improvements
Better mental clarity and focus
Improved mood and emotional stability
Enhanced libido and sexual function
Better sleep quality

Months 3-6:

Significant relief across all symptom categories
Weight management becomes easier
Muscle tone and strength returning
Feeling “like yourself again”
Restored quality of life and enjoyment

You’re Not Alone:

Many women reach this level of symptoms before seeking help. The most common thing we hear is: “I wish I had done this sooner.”

Real Patient Success Stories:

“George and his staff are great to work with and very knowledgeable. I’ve had fun learning and doing the peptide program. It’s been very smooth. I have felt better than I have in some time…” – Patient Testimonial

“The O-Shot… was minimally invasive, and not painful at all. My orgasms are easier to achieve and last longer. I highly recommend Dr. Ibrahim and the staff.” – Patient Testimonial

Financial Considerations:

We understand that investing in your health is a significant decision. During your consultation, we will:

Provide transparent cost information
Discuss treatment options at different price points
Explain what’s included in your care
Work with you to find an approach that fits your situation

Most women find that feeling like themselves again is priceless.

Don’t Spend Another Day Suffering… Schedule Your Priority Consultation:

Call now for priority scheduling: (864) 202-6583 Email: info@HormoneTherapyGreenvilleSC.com

We typically reserve priority appointments for women with significant symptoms. Mention your assessment score when calling.

Remember: This assessment is for educational purposes only and does not constitute medical advice. Please consult with a qualified healthcare provider for personalized recommendations.

HIPAA Disclaimer

Severe Symptoms

Immediate Evaluation Recommended

Thank you for completing the Biltmore Restorative Medicine Female Hormone Assessment.

Based on your responses, your total symptom score is {calculation-1}/165, which falls into the Severe Symptoms range.

What This Means… And Why It Matters:

Your symptoms indicate a critical hormonal imbalance that is severely impacting nearly every aspect of your daily life. You may feel like you’re barely surviving each day, and you’re likely experiencing profound effects on your physical health, emotional wellbeing, relationships, and overall quality of life.

This level of hormonal disruption requires immediate medical attention.

We Want You to Know:

You don’t have to live like this. What you’re experiencing is not “just part of getting older,” and you’re not “being dramatic” or “too sensitive.” Your symptoms are real, they’re severe, and most importantly… they are treatable.

Many women wait far too long to seek help, suffering unnecessarily for months or years. We’re glad you took this assessment, because recognizing the severity of your symptoms is the first critical step toward feeling like yourself again.

The Reality of Your Current Situation:

With severe symptoms at this level, you’re likely experiencing:

Physical Impact:

Debilitating fatigue making basic tasks exhausting
Significant weight gain despite diet efforts
Multiple hot flashes and night sweats disrupting daily life
Severe sleep disruption affecting everything else
Joint pain and physical discomfort
Loss of strength and physical capability

Emotional & Mental Impact:

Mood swings affecting your relationships
Anxiety or depression that may feel overwhelming
Severe “brain fog” affecting work performance
Memory issues causing concern and frustration
Feeling like you’ve lost yourself
Struggling to cope with daily stress

Relationship & Intimacy Impact:

Complete loss of libido or sexual desire
Painful intercourse or severe vaginal dryness
Strain on your relationship with your partner
Withdrawal from social activities
Feeling disconnected from loved ones

Quality of Life Impact:

Not enjoying activities you used to love
Difficulty fulfilling work or family responsibilities
Feeling older than your years
Loss of confidence and self-esteem
Questioning if you’ll ever feel good again

Health Risks of Prolonged Severe Hormonal Imbalance:

Beyond quality of life, severe untreated hormonal imbalance increases risks for:

Accelerated bone loss and osteoporosis
Cardiovascular disease
Cognitive decline and dementia risk
Metabolic syndrome and diabetes
Depression and anxiety disorders
Accelerated aging processes

Your health… both now and in the future… depends on addressing these imbalances.

Immediate Action Required:

URGENT: Please Schedule Your Consultation Within the Next 7 Days

This is not about sales or pressure—this is about your health and wellbeing. Women with symptom scores in your range need comprehensive medical evaluation and treatment as soon as possible.

Why Dr. George K. Ibrahim is Your Best Choice:

When symptoms are this severe, you need the highest level of expertise:

Dr. Ibrahim’s Unique Qualifications:

30+ Years Experience: Treating thousands of women with hormonal imbalances
Urologist: Deep understanding of women’s physiology and sexual health
Fellowship in Anti-Aging Medicine: Advanced training in hormone optimization
Only A4M Certified Fellow in Western NC: Highest level of hormone therapy certification
Member, North American Menopause Society: Specialized menopause expertise
Advisory Board Member, The Menopause Association:
Comprehensive Approach: Treats the whole person, not just symptoms

What Sets Biltmore Restorative Medicine Apart:

Convenient laboratory services (no waiting, no running around)
Fast hormone testing available
Personalized treatment plans, never one-size-fits-all
Decade+ of experience with bioidentical hormones
Integration of multiple therapies for optimal results
Compassionate, judgment-free environment

Your Comprehensive Evaluation Will Include:

Urgent Medical Assessment:

Thorough review of all symptoms and their severity
Complete medical history and current health status
Discussion of how symptoms are affecting your life
Evaluation of any urgent health concerns

Complete Hormone & Health Panel:

Full female hormone panel (estrogen, progesterone, testosterone)
Thyroid function (often contributing to severe symptoms)
Metabolic markers and nutritional deficiencies
Additional testing based on your specific symptoms
Results review and detailed explanation

Comprehensive Treatment Protocol:

At your symptom severity, we typically recommend aggressive but safe treatment:

Bioidentical Hormone Pellet Implants (Most Recommended):

Fastest, most consistent relief for severe symptoms
Steady hormone levels 24/7 for 3-4 months
No pills to remember, no creams to apply
Proven most effective for significant symptom relief

Additional Therapies May Include:

Peptide therapy for cellular optimization
Thyroid support if needed
Nutritional supplementation
O-Shot for sexual wellness and urinary health
Sleep optimization strategies
Stress management support

Aggressive Symptom Management:

We won’t make you wait months to feel better
Initial treatments can begin immediately after testing
Follow-up within 2-3 weeks to assess response
Adjustments made quickly if needed
Goal: Noticeable improvement within 2-4 weeks

Timeline for Relief:

Because your symptoms are severe, here’s what you can realistically expect:

Week 1-2:

Reduction in hot flashes and night sweats
Beginning of sleep improvement
Initial energy lift
Hope restored (this alone is powerful)

Week 3-6:

Significant improvement in energy levels
Mood stabilization and emotional relief
Mental clarity beginning to return
Sleep quality dramatically improved
Physical symptoms improving

Month 2-3:

Most symptoms substantially reduced
Feeling more like yourself
Engaging in life again
Relationships improving
Confidence returning

Month 3-6:

Full optimization achieved
Quality of life restored
Sustained improvements
“I wish I’d done this years ago”

Real Transformations:

Women who come to us with severe symptoms often tell us:

“I didn’t realize how bad things had gotten until I started feeling better.”

“I got my life back. My marriage is better, my work performance improved, and I actually want to do things again.”

“Dr. Ibrahim listened to me when other doctors told me this was just ‘normal aging.’ He believed me, and he helped me.”

“I only wish I hadn’t waited so long to get help.”

Financial Investment in Your Health:

We understand this is a significant decision, especially when you’re already feeling overwhelmed. During your consultation, we will:

Provide complete cost transparency
Discuss all treatment options and associated costs
Work with you to develop an affordable approach
Never pressure you into treatments you’re not comfortable with

Important: Many women find that even if hormone therapy requires an investment, the return in terms of quality of life, productivity, relationships, and health is immeasurable.

What You Need to Do Right Now:

Step 1: Call Our Office Today Mention your assessment score and that you need priority scheduling for severe symptoms.

Step 2: Prepare for Your Consultation

List your top 5 most troubling symptoms
Write down questions you have
Bring current medications list
Recent lab work if available

Step 3: Make the Commitment to Yourself Decide that you’re worth feeling better. You deserve to feel like yourself again.

Important Safety Note:

While we want to help you as quickly as possible, if you are experiencing:

Suicidal thoughts or severe depression
Chest pain or difficulty breathing
Unexplained bleeding
Severe abdominal pain
Any medical emergency

Please seek immediate medical attention at your nearest emergency room or call 911.

This assessment is for hormone-related symptom evaluation, not emergency medical conditions.

Take Action Today—You Deserve to Feel Better:

Call: (864) 202-6583 Email: info@HormoneTherapyGreenvilleSC.com

We prioritize appointments for women with severe symptoms. You will not be made to wait weeks—we understand the urgency.

A Personal Message from Biltmore Restorative Medicine:

If you’re reading this and feeling overwhelmed, please know that we see women in your situation regularly. Many arrive in our office feeling hopeless, exhausted, and wondering if they’ll ever feel normal again.

We’re here to tell you: There is hope. You can feel better. You will feel like yourself again.

Dr. Ibrahim and our entire team are committed to helping women just like you reclaim their vitality, health, and quality of life. We don’t just treat symptoms—we restore wellness.

You took the first step by completing this assessment. Now take the next step and call us.

You don’t have to do this alone. We’re here to help.

This assessment is for educational purposes only and does not constitute medical advice. Severe symptoms require professional medical evaluation. Please schedule your consultation with Dr. Ibrahim for personalized medical recommendations and treatment.

Your health and wellbeing matter. Call today.

HIPAA Disclaimer

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