Intake Form — Oshun Cosmetic Services

About you

Full name

Phone

Date of birth

II.

This determines which assessment questions apply to you. Hormonal symptom screens differ by biological sex.

Female Includes vaginal, menstrual, and menopause-related questions Male Includes erectile, libido, and andropause-related questions

III.

For each item below, mark the level that best describes what you've been experiencing.

Physical exhaustion (fatigue, lack of energy, stamina or motivation)

Sleep problems (difficulty falling asleep or sleeping through the night)

Irritability (mood swings, feeling aggressive, angers easily)

Anxiety (feeling overwhelmed, panicky, or nervous)

Decline in drive or interest (loss of "zest for life", feeling down or sad)

Joint and muscular symptoms (poor recovery, inability to add muscle, joint pain)

Difficulties with memory (concentration, finding words, retaining information)

Sweating (night sweats or increased episodes of sweating)

Hair loss, thinning or change in texture of hair

Feeling cold all the time, having cold hands or feet

Headaches or migraines (increase in frequency or intensity)

Weight (difficulty losing weight despite diet/exercise)

Bladder problems (difficulty urinating, increased need to urinate)

IV.

Other symptoms, current medications, or concerns Dr. Rockhead should know about

Reviewed by Dr. Charles Rockhead. Confidential.

✓

Your assessment has been received. Dr. Rockhead will review it before your visit. If anything stands out we'll reach out by WhatsApp or email.