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Renew Health and Wellness
Bioidentical Hormone Replacement Weight Loss Center
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Hormone Health Test
Our Three Minute Hormone Health Test can start you down the path to a restored life. Take the test and we’ll send you immediate results and then follow up with potentially life-changing information.
Intimate Wellness
Female Sexual Wellness
About Female Sexual Wellness
FemiWave®
FemiWave uses low-intensity shockwaves, a clinically-proven procedure that treats the root cause and increases blood flow to restore healthy tissue. Available at all locations
O-Shot
Offered at out Richmond and Fredericksburg Locations
Votiva by Inmode
Vaginal Rejuvenation (Richmond Location Only)
Viveve for Women’s Intimate Health
Offered at our Greenville, SC location
Male Sexual Wellness
About Male Sexual Wellness
RenewPulse Therapy
RenewPulse is a safe, comfortable and proven procedure for men to optimize sexual performance and to reverse the effects of Erectile Dysfunction (ED) due to poor blood flow.
GAINSWave®
Shockwave therapy used to treat erectile dysfunction, Peyronie’s disease, and optimize sexual performance.
Blog articles for ED
Weight Loss
Medically Monitored Weight Loss
MIC Injections
Glutathione
Weight Loss – Blog
Botox®
Botox® Injections
Dermal Fillers
Skin Rejuvenation
About Laser Hair Removal
Motus AY Laser Hair Removal Treatment (RVA Only)
Viora V-IPL
Microneedling
About Skin Rejuvenation
Morpheus8 (Richmond Location only)
Exceed Microneedling (Richmond Location only)
Crown Aesthetics SkinPen
Offered at our Fredericksburg, VA and Greenville, SC locations Automated Micro-Needling (also known as Collagen Induction Therapy)
Body Contouring
About Body Contouring?
Physiq Body Contouring (Richmond Location only)
VIORA V-ST
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Hormone Health Test
BHRT for Women
Bio-Identical Hormone Therapy
Female Sexual Wellness
FemiWave®
O-Shot
Votiva by Inmode
Vaginal Rejuvenation (Richmond Location Only)
Viveve for Women’s Intimate Health
Vaginal Rejuvenation (Greenville Location Only)
BHRT for Men
Bio-Identical Hormone Therapy
Male Sexual Wellness
RenewPulse Therapy
GAINSWave®
Weight Loss Program
Medically Supervised Monitored Weight Loss
MIC Injections
Glutathione
Skin Rejuvenation
Botox® Injections
Dermal Fillers
HydraFacial MD
Richmond Location Only
Crown Aesthetics SkinPen
Microneedling (Fredericksburg & Greenville)
Exceed Microneedling
Richmond location only
Morpheus8
Skin Tightening/Body Contouring Richmond Location Only
Motus AY Laser Hair Removal
Richmond Location Only
Viora V-IPL
Greenville Location Only
Physiq
Body Contouring • Richmond Location Only
VIORA V-ST
Skin Tightening Therapy • Greenville Location
Skinprint Products
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Symptoms Questionnaire
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Patient Forms
Symptoms Questionnaire
Existing Patient Symptoms Questionnaire
If you are a new patient please do not fill out this form.
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1
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- Patient Information
0%
IMPORTANT: PLEASE SUBMIT THIS FORM TO RENEW TWO WEEKS PRIOR TO YOUR INSERT APPOINTMENT TO AVOID RESCHEDULING
This information is necessary for your Renew Provider to properly diagnose you in order to achieve and maintain therapeutic hormone levels. Thank you.
Patient Name:
(Required)
First
Last
Email
(Required)
Enter Email
Confirm Email
Phone
(Required)
Your Gender:
(Required)
Female
Male
Date of Birth:
(Required)
MM slash DD slash YYYY
Please choose the closest location:
(Required)
Fredericksburg, VA
Greenville, SC
Richmond, VA
Do you have a uterus?
Yes
No
How many times a week do you exercise?
Please select one.
I don't exercise
1
2
3
4
5
For proper dosing, please rate your symptoms below based on how you are currently feeling: 0 means you have no symptoms of this type at all / 1 means you have very mild symptoms of this type 5 would be moderate symptoms and 10 would mean you have severe symptoms of this type.
(p)
0
1
2
3
4
5
6
7
8
9
10
Sleep Disturbances
Depression
Irritability
Anxiety
Mood Swings
Migraine Headaches
Palpitations
Comments, if any with the symptoms above
(E)
0
1
2
3
4
5
6
7
8
9
10
Painful Intercourse
Night Sweats
Hot Flashes
Dry Skin
Chronic Fatigue
Restless Leg Syndrome
Hair Loss
0 means you have no symptoms of this type at all / 1 means you have very mild symptoms of this type 5 would be moderate symptoms and 10 would mean you have severe symptoms of this type.
(E)
1
2
3
4
5
6
7
8
9
10
Night Sweats
Hot Flashes
Dry Skin
Chronic Fatigue
Restless Leg Syndrome
0 means you have no symptoms of this type at all / 1 means you have very mild symptoms of this type 5 would be moderate symptoms and 10 would mean you have severe symptoms of this type.
Breast Tenderness?
Yes
No
Bloating?
Yes
No
Bleeding/Spotting?
Yes
No
Comments, if any with the symptoms above
(T)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Fatigue
Low Sex Drive
Poor Focus
Body/Joint Pains
Memory Lapses
Low Exercise Tolerance
Loss of Muscle Tone
0 means you have no symptoms of this type at all / 1 means you have very mild symptoms of this type 5 would be moderate symptoms and 10 would mean you have severe symptoms of this type.
(T)
(Required)
0
1
2
3
4
5
6
7
8
9
10
Fatigue
Low Sex Drive
Erectile Dysfunction
Poor Focus
Body Joint Pains
Memory Lapses
Low Exercise Tolerance
Loss of Muscle Tone
0 means you have no symptoms of this type at all / 1 means you have very mild symptoms of this type 5 would be moderate symptoms and 10 would mean you have severe symptoms of this type.
Comments, if any with the symptoms above
Patient Comments or any changes in medical conditions or medications since last report:
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