Language
English (US)
Spanish (Latin America)
SouthPointe Plaza
1901 E 32nd St Ste 20
Joplin MO
(417) 781-2046
www.apclinic.net
Female Hormone Symptom Checklist
Date
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Day
Year
Date
Patient Name
*
First Name
Middle Name
Last Name
Patient Birth Date
*
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Patient Gender
*
Male
Female
Transgender
Other
How would you describe your health at the present?
*
Very good
Good
Fair
Poor
Very poor
How much do you think your bladder problems affects your life?
*
Not at all
A little
Moderately
A lot
Category 1 | Sex Hormone Imbalance
Acne
Bone loss
Cystic ovaries
Depressed mood
Fibrocystic breasts
Foggy thinking
Headaches
Heart palpitations
Heavy menses
Hot flashes
Increased body/facial hair
Irritability
Low libido/decreased sexual function
Mood swings (PMS)
Night sweats
Urinary incontinence
Uterine fibroids
Vaginal dryness
Weight gain
Category 2 | Adrenal Hormone Imbalance
Aches/pains
Afternoon/evening fatigue
Allergies
Anxiety
Autoimmune disease
Bone loss
Chronic health problems
Depression
Diabetes/prediabetes
History of steroid usage
Low blood sugar
Morning fatigue
Salt/sugar cravings
Sleep disturbances
Susceptibility to infections
Weight gain
Category 3 | Thyroid Hormone Imbalance
Aches/pains
Anxiety
Brittle nails
Cold hands/feet
Constipation
Depression
Dry skin
Elevated cholesterol
Fatigue
Feeling cold
Foggy thinking
Headaches
Heart palpitations
Inability to lose weight
Infertility
Low libido
Menstrual irregularities
Sleep disturbances
Thinning hair
Weight gain
Category 4 | Metabolic Imbalance
Diabetes (or family history)
Elevated cholesterol
Fatigue
Gestational diabetes (or family history)
Heart disease/stroke (or family history)
High blood pressure
High blood sugar
Insulin resistance
Low physical activity
Low thyroid/decreased sexual function
PCOS
Salt/sugar cravings
Smoking (or history of)
Thyroid disorders
Weight gain
Category 5 | Neurotransmitter Imbalance
ADD?ADHD
Addictive behaviors
Anxious/nervous
Autism spectrum disorder
Depressed
Developmental delays
Eating disorders
Irritable
Methylation deficits
Mood swings
OCD
Panic attacks
PMDD (Premenstrual Dysphoric Disorder
Sleep disturbed
Tearful
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