Hormone Balance Asessment
This information will be reviewed by our hormone consultant to provide a custom-tailored prescription to fit your needs.
Name
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Email
example@example.com
Phone Number
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Keep in mind that
too much of a hormone
can often look the same as
too little of a hormone
.
Symptom Group One
None
Slightly
Moderate
Severe
Extreme
Difficulty concentrating or remembering
Difficulty with Sleep (insomnia)
Depressed or Unhappy
Anxious
Headaches
Moodiness/ Emotional Swings
Painful / Swollen Breasts
Weight Gain/ Bloating
PMS
Symptom Group Two
None
Slightly
Moderate
Severe
Extreme
Night Sweats
Difficulty Remembering Things
Hot Flashes
Vaginal Dryness
Dry Hair / Skin
Incontinence
Frequent Urinary Tract Infections
Inability ro Reach Orgasm
Painful Intercourse
Symptom Group Three
None
Slightly
Moderate
Severe
Extreme
Loss of Libido
Lack of Desire to be Intimate
Loss of Motivation
Flat Mood
Diminished Wellbeing
Symptom Group Four
None
Slightly
Moderate
Severe
Extreme
Puffiness and Bloating
Rapid Weight Gain
Mood Swings
Anxious Depression
Insomnia
Weepiness
Cervical Dysplasia (abnormal pap smear)
Breast Tenderness
Heavy Bleeding
Migraine / Headaches
Foggy Thinking
Gallbladder Problems
Symptom Group Five
None
Slightly
Moderate
Severe
Extreme
Acne
Excessive Hair on the Face and Arms
Thinning Hair on the Head
Ovarian Cysts
Polycystic Ovary Syndrome (PCOS)
Hypoglycemia and/or Unstable Blood Sugar
Infertility
Mid-Cycle Pain
Symptom Group Six
None
Slightly
Moderate
Severe
Extreme
Debilitating Fatigue
Unstable Blood Sugar
Low Blood Pressure
Intolerance to Exercise
Waking up in the Morning and Not Feeling Refreshed
Feel Physically Exhausted, but your mind continues to race
Achy Muscles and/or Joints
Struggling to Lose Weight in Spite of Dieting and Exercising
Waking in the Middle of the Night
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