Listen to your Body - Michelle Buffalini, CRNP

Schedule an Appointment Today. Walk-ins are also welcome!

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- Mens Health Assessment
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ASSESSMENTS

Assessments

Biote Female Health Assessment Questionnaire

Name:

Email:

Phone:

Date:

Free Text

Please mark the appropriate box for each symptom you may be experiencing.

Free Text

SYMPTOMS

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

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

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

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Irritability (mood swings, feeling aggressive, angers easily)

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Anxiety (feeling overwhelmed, feeling panicky, or feeling nervous)

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

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

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Joint and muscular symptoms (joint pain, muscle weakness, poor recovery after exercise)

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Difficulties with memory (concentration, finding the right word, or retaining information)

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Vaginal dryness or difficulty with sexual intercourse

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Sexual problems (change in desire, activity, orgasm and/or satisfaction)

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Sweating (night sweats or increased episodes of sweating)

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Hot Flashes (burst that starts in chest and lasts for short duration)

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Hair loss, thinning or change in texture of hair

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Headaches or migraines (increase in frequency or intensity)

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Feeling cold all the time, having cold hands or feet

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Weight (difficulty losing weight despite diet/exercise)

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Bladder problems (difficulty in urinating, increased need to urinate, incontinence)

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Other symptoms or unique health circumstances to take into consideration:

Thank you for submitting your information.

We will get back to you as soon as possible.

Oops, there was an error sending your message.
Please try again later.

Biote Male Health Assessment Questionnaire

Name:

Email:

Phone:

Date:

Free Text

Please mark the appropriate box for each symptom you may be experiencing.

Free Text

SYMPTOMS

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

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

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

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Irritability (mood swings, feeling aggressive, angers easily)

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Anxiety (feeling overwhelmed, feeling panicky, or feeling nervous)

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

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

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

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

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Difficulties with memory (concentration, finding the right word, or retaining information)

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Sexual Desire or Performance (reduced or diminished)

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Erectile changes (weaker erections, loss of morning erections)

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Ejaculations (infrequent or absent)

NONE

MILD

Option 3

SEVERE

VERY SEVERE

Sweating (night sweats or increased episodes of sweating)

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Hair loss, rapid or thinning

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Feeling cold all the time, having cold hands or feet

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Headaches or migraines (increase in frequency or intensity)

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Weight (difficulty losing weight despite diet/exercise)

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Bladder problems (difficulty in urinating, increased need to urinate, incontinence)

NONE

MILD

MODERATE

SEVERE

VERY SEVERE

Other symptoms or unique health circumstances to take into consideration:

Thank you for submitting your information.

We will get back to you as soon as possible.

Oops, there was an error sending your message.
Please try again later.

Looking for health services?

Request a free phone consultation

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My goal is to enable you to live a quality life and feel great from the inside out.

SERVICES

Biote Hormone Replacement

Wellness Physical

School Physical

PPD testing

IV hydration/IV vitamin Supplementation

B12 injections

SIck visits - such as - bronchitis, pneumonia, minor lacerations, suture or staple removal, strep throat, rapid strep and rapid flu testing, ear infections, exacerbation of asthma or copd, gastroenteritis, iv hydration for recent flu symptoms, sinus infections, allergies, rash, UTI, Tick bites, insect bites, minor injury or illness

Labs- wellness yearly labs

vitamins, thyroid, B12, vitamin D

Hormone Levels and more

QUICK LINKS

HOME
ABOUT
SERVICES
BIOTE SERVICES
BIOTE NUTRACEUTICALS
HAIR REMOVAL
- TRITON
- TRITON PRICING
IV DRIPS
MEDICATION MIX-INS/IVP/IV INJECTIONS
VITAMINS
WEIGHT LOSS
CONTACT
ASSESSMENTS
- Womens Health Assessment
- Mens Health Assessment
TESTIMONIALS
EVENTS

CONTACT

Schedule an Appointment Today! Walk-ins are also welcome!

(720) 263-1384

Fax-724-765-2264

buffaliniprimarycare@gmail.com

606 S. 4th Ave

Brighton, CO 80601

Visit by appointment only

Accepting HSA, FSA, Credit card, check or cash

Accept Medicare / Blue Cross / Blue Shield

Copyright 2024 BUFFALINI Primary Care LLC

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