Hormonal Health Evaluation
Are you a man or a woman?
Man
Woman
Adrenal Gland
1. Stress seems to easily cause noticeable symptoms like flushing or heart palpitations
No
Mild
Moderate
Severe
2. Brain fog, forgetting basic things, a sense of mild confusion
No
Mild
Moderate
Severe
3. Unexplained anxiety
No
Mild
Moderate
Severe
4. Low or high blood pressure
No
Mild
Moderate
Severe
5. Troubles falling asleep and/or wakes up after 2-4 hours of sleep and unable to fall back asleep within 30 minutes
No
Mild
Moderate
Severe
6. Alternating areas of pain, tenderness, hot, sore, and sensitive to the touch or diagnosed with chronic fatigue syndrome or fibromyalgia
No
Mild
Moderate
Severe
Thyroid Gland
1. Hands and feet frequently feel cold or chilled
*
No
Mild
Moderate
Severe
2. Constantly feeling sleepy
*
No
Mild
Moderate
Severe
3. Feel slow-moving, sluggish
*
No
Mild
Moderate
Severe
4. Constipated regularly
*
No
Mild
Moderate
Severe
5. Dry or scaly skin
*
No
Mild
Moderate
Severe
6. Hair feels coarse and/or brittle
*
No
Mild
Moderate
Severe
7. Losing hair and/or outer third of eyebrow
*
No
Mild
Moderate
Severe
8. Heavy menstrual periods (men answer no)
*
No
Mild
Moderate
Severe
9. Weight gain despite changes in diet
*
No
Mild
Moderate
Severe
10. Take thyroid medication
*
No
Mild
Moderate
Severe
11. Decrease in muscle mass, with an increase in body fat
No
Mild
Moderate
Severe
12. Loss of sex drive
No
Mild
Moderate
Severe
13. Suffer from erectile dysfunction
No
Mild
Moderate
Severe
14. After 35 years of age started having troubles concentrating and/or lack of feeling sharp
No
Mild
Moderate
Severe
15. Unexplained depression and decreased since of wellbeing after 35 years of age
No
Mild
Moderate
Severe
Additional Symptoms
Please answer the following questions, even if you have had hysterectomy or have gone through menopause, as if you were still having your cycle.
11. Anxious, irritable, aggressive or hostile
No
Mild
Moderate
Severe
12. Breast tenderness, swelling
No
Mild
Moderate
Severe
13. Being easily overwhelmed, sad, excessively irritable or irrational
No
Mild
Moderate
Severe
14. Abnormally heavy or scanty flow, pain with cycle, periods occur irregularly or absent (not in menopause), diagnosed with fibroids, endometresosis, ovarian cysts or fibroids
No
Mild
Moderate
Severe
15. Pain when you ovulate
No
Mild
Moderate
Severe
16. Menstrual blood is dark and clots are present
No
Mild
Moderate
Severe
17. Troubles getting pregnant
No
Mild
Moderate
Severe
18. Sexual intercourse is uncomfortable
No
Mild
Moderate
Severe
19. Increased growth of dark facial and/or body hair
No
Mild
Moderate
Severe
20. Interest in having sex is low
No
Mild
Moderate
Severe
21. Had a hysterectomy, uterine ablations, D&C for heavy bleeding
No
Mild
Moderate
Severe
22.Hot flashes or spontaneous sweating
No
Mild
Moderate
Severe
Please list your top 5 complaints.
1 - If you don’t have 5 that's okay.
Please list your top 5 complaints.
2
Please list your top 5 complaints.
3
Please list your top 5 complaints.
4
Please list your top 5 complaints.
5
Name
*
First Name
Last Name
Age
*
Email
example@example.com
SMS Phone Number
-
Area Code
Phone Number
Adrenal Glands Calculation
Thyroid Gland Calculation
Thyroid - Men
Thyroid - Women
Total - Female
Total - Male
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Get Your Evaluation Results
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