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Updated Hormone Symptom Review - Female
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
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10
Section 1. Please rate each of these symptoms as you currently feel. Yes, some are repetitive but for good reason. Please do not "over think" these as you answer them. Remember, we are asking for YOUR answers. Please rate each of the following 14 medical conditions.
*
This field is required.
None
Mild
Moderate
Severe
Hot Flashes
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Sleep Disturbances
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Dry Skin
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Foggy Thinking
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Heart Palpitations
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Painful Intercourse
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Low Libido
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Night Sweats
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Vaginal Dryness/Atrophy
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Headaches
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Memory Lapses
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Yeast Infections
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Depression
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Bone Loss
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Hot Flashes
Sleep Disturbances
Dry Skin
Foggy Thinking
Heart Palpitations
Painful Intercourse
Low Libido
Night Sweats
Vaginal Dryness/Atrophy
Headaches
Memory Lapses
Yeast Infections
Depression
Bone Loss
None
Row 0, Column 0
Mild
Row 0, Column 1
Moderate
Row 0, Column 2
Severe
Row 0, Column 3
None
Row 1, Column 0
Mild
Row 1, Column 1
Moderate
Row 1, Column 2
Severe
Row 1, Column 3
None
Row 2, Column 0
Mild
Row 2, Column 1
Moderate
Row 2, Column 2
Severe
Row 2, Column 3
None
Row 3, Column 0
Mild
Row 3, Column 1
Moderate
Row 3, Column 2
Severe
Row 3, Column 3
None
Row 4, Column 0
Mild
Row 4, Column 1
Moderate
Row 4, Column 2
Severe
Row 4, Column 3
None
Row 5, Column 0
Mild
Row 5, Column 1
Moderate
Row 5, Column 2
Severe
Row 5, Column 3
None
Row 6, Column 0
Mild
Row 6, Column 1
Moderate
Row 6, Column 2
Severe
Row 6, Column 3
None
Row 7, Column 0
Mild
Row 7, Column 1
Moderate
Row 7, Column 2
Severe
Row 7, Column 3
None
Row 8, Column 0
Mild
Row 8, Column 1
Moderate
Row 8, Column 2
Severe
Row 8, Column 3
None
Row 9, Column 0
Mild
Row 9, Column 1
Moderate
Row 9, Column 2
Severe
Row 9, Column 3
None
Row 10, Column 0
Mild
Row 10, Column 1
Moderate
Row 10, Column 2
Severe
Row 10, Column 3
None
Row 11, Column 0
Mild
Row 11, Column 1
Moderate
Row 11, Column 2
Severe
Row 11, Column 3
None
Row 12, Column 0
Mild
Row 12, Column 1
Moderate
Row 12, Column 2
Severe
Row 12, Column 3
None
Row 13, Column 0
Mild
Row 13, Column 1
Moderate
Row 13, Column 2
Severe
Row 13, Column 3
1
of 14
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11
Section 2. Please rate each of these symptoms as you currently feel. Yes, some are repetitive but for good reason. Please do not "over think" these as you answer them. Remember, we are asking for YOUR answers. Please rate each of the following 11 medical conditions.
*
This field is required.
None
Mild
Moderate
Severe
Water Retention
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Breast Swelling/Tenderness
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Craving for Sweets
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Fibrocystic Breasts
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Uterine Fibroids
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Nervousness/Anxiety/Irritability
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Heavy, Irregular Menses
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Fatigue
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Weight Gain
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Mood Swings
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Low Thyroid Symptoms
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Water Retention
Breast Swelling/Tenderness
Craving for Sweets
Fibrocystic Breasts
Uterine Fibroids
Nervousness/Anxiety/Irritability
Heavy, Irregular Menses
Fatigue
Weight Gain
Mood Swings
Low Thyroid Symptoms
None
Row 0, Column 0
Mild
Row 0, Column 1
Moderate
Row 0, Column 2
Severe
Row 0, Column 3
None
Row 1, Column 0
Mild
Row 1, Column 1
Moderate
Row 1, Column 2
Severe
Row 1, Column 3
None
Row 2, Column 0
Mild
Row 2, Column 1
Moderate
Row 2, Column 2
Severe
Row 2, Column 3
None
Row 3, Column 0
Mild
Row 3, Column 1
Moderate
Row 3, Column 2
Severe
Row 3, Column 3
None
Row 4, Column 0
Mild
Row 4, Column 1
Moderate
Row 4, Column 2
Severe
Row 4, Column 3
None
Row 5, Column 0
Mild
Row 5, Column 1
Moderate
Row 5, Column 2
Severe
Row 5, Column 3
None
Row 6, Column 0
Mild
Row 6, Column 1
Moderate
Row 6, Column 2
Severe
Row 6, Column 3
None
Row 7, Column 0
Mild
Row 7, Column 1
Moderate
Row 7, Column 2
Severe
Row 7, Column 3
None
Row 8, Column 0
Mild
Row 8, Column 1
Moderate
Row 8, Column 2
Severe
Row 8, Column 3
None
Row 9, Column 0
Mild
Row 9, Column 1
Moderate
Row 9, Column 2
Severe
Row 9, Column 3
None
Row 10, Column 0
Mild
Row 10, Column 1
Moderate
Row 10, Column 2
Severe
Row 10, Column 3
1
of 11
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12
Section 3. Please rate each of these symptoms as you currently feel. Yes, some are repetitive but for good reason. Please do not "over think" these as you answer them. Remember, we are asking for YOUR answers. Please rate each of the following 14 medical conditions.
*
This field is required.
None
Mild
Moderate
Severe
Swollen Breasts
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Headaches
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Anxiety
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Irregular Menses
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Cramping
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Infertility
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Acne
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Weight Gain
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Low Libido
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Mood Swings
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Depression
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
PMS
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Fuzzy Thinking
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Joint Pain
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Swollen Breasts
Headaches
Anxiety
Irregular Menses
Cramping
Infertility
Acne
Weight Gain
Low Libido
Mood Swings
Depression
PMS
Fuzzy Thinking
Joint Pain
None
Row 0, Column 0
Mild
Row 0, Column 1
Moderate
Row 0, Column 2
Severe
Row 0, Column 3
None
Row 1, Column 0
Mild
Row 1, Column 1
Moderate
Row 1, Column 2
Severe
Row 1, Column 3
None
Row 2, Column 0
Mild
Row 2, Column 1
Moderate
Row 2, Column 2
Severe
Row 2, Column 3
None
Row 3, Column 0
Mild
Row 3, Column 1
Moderate
Row 3, Column 2
Severe
Row 3, Column 3
None
Row 4, Column 0
Mild
Row 4, Column 1
Moderate
Row 4, Column 2
Severe
Row 4, Column 3
None
Row 5, Column 0
Mild
Row 5, Column 1
Moderate
Row 5, Column 2
Severe
Row 5, Column 3
None
Row 6, Column 0
Mild
Row 6, Column 1
Moderate
Row 6, Column 2
Severe
Row 6, Column 3
None
Row 7, Column 0
Mild
Row 7, Column 1
Moderate
Row 7, Column 2
Severe
Row 7, Column 3
None
Row 8, Column 0
Mild
Row 8, Column 1
Moderate
Row 8, Column 2
Severe
Row 8, Column 3
None
Row 9, Column 0
Mild
Row 9, Column 1
Moderate
Row 9, Column 2
Severe
Row 9, Column 3
None
Row 10, Column 0
Mild
Row 10, Column 1
Moderate
Row 10, Column 2
Severe
Row 10, Column 3
None
Row 11, Column 0
Mild
Row 11, Column 1
Moderate
Row 11, Column 2
Severe
Row 11, Column 3
None
Row 12, Column 0
Mild
Row 12, Column 1
Moderate
Row 12, Column 2
Severe
Row 12, Column 3
None
Row 13, Column 0
Mild
Row 13, Column 1
Moderate
Row 13, Column 2
Severe
Row 13, Column 3
1
of 14
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13
Section 4. Please rate each of these symptoms as you currently feel. Yes, some are repetitive but for good reason. Please do not "over think" these as you answer them. Remember, we are asking for YOUR answers. Please rate each of the following 5 medical conditions.
*
This field is required.
None
Mild
Moderate
Severe
Somnolence
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Mild Depression
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Candida Exacerbations
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Gastrointestinal Bloating
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Breast Swelling
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Somnolence
Mild Depression
Candida Exacerbations
Gastrointestinal Bloating
Breast Swelling
None
Row 0, Column 0
Mild
Row 0, Column 1
Moderate
Row 0, Column 2
Severe
Row 0, Column 3
None
Row 1, Column 0
Mild
Row 1, Column 1
Moderate
Row 1, Column 2
Severe
Row 1, Column 3
None
Row 2, Column 0
Mild
Row 2, Column 1
Moderate
Row 2, Column 2
Severe
Row 2, Column 3
None
Row 3, Column 0
Mild
Row 3, Column 1
Moderate
Row 3, Column 2
Severe
Row 3, Column 3
None
Row 4, Column 0
Mild
Row 4, Column 1
Moderate
Row 4, Column 2
Severe
Row 4, Column 3
1
of 5
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14
Section 5. Please rate each of these symptoms as you currently feel. Yes, some are repetitive but for good reason. Please do not "over think" these as you answer them. Remember, we are asking for YOUR answers. Please rate each of the following 15 medical conditions.
*
This field is required.
None
Mild
Moderate
Severe
Fatigue, Prolonged
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Memory Problems
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Decreased Libido
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Muscle Weakness
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Heart Palpitations
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Bone Loss
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Incontinence
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Fibromyalgia
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Mental Fuzziness
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Depression
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Blunted Motivation
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Diminished Feeling of Well-Being
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Thinning Skin
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Vaginal Dryness
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
General Aches/Pains
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Row 14, Column 3
Fatigue, Prolonged
Memory Problems
Decreased Libido
Muscle Weakness
Heart Palpitations
Bone Loss
Incontinence
Fibromyalgia
Mental Fuzziness
Depression
Blunted Motivation
Diminished Feeling of Well-Being
Thinning Skin
Vaginal Dryness
General Aches/Pains
None
Row 0, Column 0
Mild
Row 0, Column 1
Moderate
Row 0, Column 2
Severe
Row 0, Column 3
None
Row 1, Column 0
Mild
Row 1, Column 1
Moderate
Row 1, Column 2
Severe
Row 1, Column 3
None
Row 2, Column 0
Mild
Row 2, Column 1
Moderate
Row 2, Column 2
Severe
Row 2, Column 3
None
Row 3, Column 0
Mild
Row 3, Column 1
Moderate
Row 3, Column 2
Severe
Row 3, Column 3
None
Row 4, Column 0
Mild
Row 4, Column 1
Moderate
Row 4, Column 2
Severe
Row 4, Column 3
None
Row 5, Column 0
Mild
Row 5, Column 1
Moderate
Row 5, Column 2
Severe
Row 5, Column 3
None
Row 6, Column 0
Mild
Row 6, Column 1
Moderate
Row 6, Column 2
Severe
Row 6, Column 3
None
Row 7, Column 0
Mild
Row 7, Column 1
Moderate
Row 7, Column 2
Severe
Row 7, Column 3
None
Row 8, Column 0
Mild
Row 8, Column 1
Moderate
Row 8, Column 2
Severe
Row 8, Column 3
None
Row 9, Column 0
Mild
Row 9, Column 1
Moderate
Row 9, Column 2
Severe
Row 9, Column 3
None
Row 10, Column 0
Mild
Row 10, Column 1
Moderate
Row 10, Column 2
Severe
Row 10, Column 3
None
Row 11, Column 0
Mild
Row 11, Column 1
Moderate
Row 11, Column 2
Severe
Row 11, Column 3
None
Row 12, Column 0
Mild
Row 12, Column 1
Moderate
Row 12, Column 2
Severe
Row 12, Column 3
None
Row 13, Column 0
Mild
Row 13, Column 1
Moderate
Row 13, Column 2
Severe
Row 13, Column 3
None
Row 14, Column 0
Mild
Row 14, Column 1
Moderate
Row 14, Column 2
Severe
Row 14, Column 3
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Section 6. Please rate each of these symptoms as you currently feel. Yes, some are repetitive but for good reason. Please do not "over think" these as you answer them. Remember, we are asking for YOUR answers. Please rate each of the following 7 medical conditions.
*
This field is required.
None
Mild
Moderate
Severe
Acne
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Deepening of Voice
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Irritability/Moodiness
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Loss of Scalp Hair
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Male-Pattern Hair Growth
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Clitoral Enlargement
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Insomnia
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Acne
Deepening of Voice
Irritability/Moodiness
Loss of Scalp Hair
Male-Pattern Hair Growth
Clitoral Enlargement
Insomnia
None
Row 0, Column 0
Mild
Row 0, Column 1
Moderate
Row 0, Column 2
Severe
Row 0, Column 3
None
Row 1, Column 0
Mild
Row 1, Column 1
Moderate
Row 1, Column 2
Severe
Row 1, Column 3
None
Row 2, Column 0
Mild
Row 2, Column 1
Moderate
Row 2, Column 2
Severe
Row 2, Column 3
None
Row 3, Column 0
Mild
Row 3, Column 1
Moderate
Row 3, Column 2
Severe
Row 3, Column 3
None
Row 4, Column 0
Mild
Row 4, Column 1
Moderate
Row 4, Column 2
Severe
Row 4, Column 3
None
Row 5, Column 0
Mild
Row 5, Column 1
Moderate
Row 5, Column 2
Severe
Row 5, Column 3
None
Row 6, Column 0
Mild
Row 6, Column 1
Moderate
Row 6, Column 2
Severe
Row 6, Column 3
1
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16
Section 7. Please rate each of these symptoms as you currently feel. Yes, some are repetitive but for good reason. Please do not "over think" these as you answer them. Remember, we are asking for YOUR answers. Please rate each of the following 6 medical conditions.
*
This field is required.
None
Mild
Moderate
Severe
Fatigue
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Craving for Sweets
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Chemical Sensitivities
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Symptoms of Low Progesterone
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Allergies
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Irritability
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Fatigue
Craving for Sweets
Chemical Sensitivities
Symptoms of Low Progesterone
Allergies
Irritability
None
Row 0, Column 0
Mild
Row 0, Column 1
Moderate
Row 0, Column 2
Severe
Row 0, Column 3
None
Row 1, Column 0
Mild
Row 1, Column 1
Moderate
Row 1, Column 2
Severe
Row 1, Column 3
None
Row 2, Column 0
Mild
Row 2, Column 1
Moderate
Row 2, Column 2
Severe
Row 2, Column 3
None
Row 3, Column 0
Mild
Row 3, Column 1
Moderate
Row 3, Column 2
Severe
Row 3, Column 3
None
Row 4, Column 0
Mild
Row 4, Column 1
Moderate
Row 4, Column 2
Severe
Row 4, Column 3
None
Row 5, Column 0
Mild
Row 5, Column 1
Moderate
Row 5, Column 2
Severe
Row 5, Column 3
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17
Section 8. Please rate each of these symptoms as you currently feel. Yes, some are repetitive but for good reason. Please do not "over think" these as you answer them. Remember, we are asking for YOUR answers. Please rate each of the following 7 medical conditions.
*
This field is required.
None
Mild
Moderate
Severe
Bone Loss
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Sleep Disturbances
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Low Libido
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Anxiety
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Depression
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Hair Loss
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Elevated Triglycerides
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Bone Loss
Sleep Disturbances
Low Libido
Anxiety
Depression
Hair Loss
Elevated Triglycerides
None
Row 0, Column 0
Mild
Row 0, Column 1
Moderate
Row 0, Column 2
Severe
Row 0, Column 3
None
Row 1, Column 0
Mild
Row 1, Column 1
Moderate
Row 1, Column 2
Severe
Row 1, Column 3
None
Row 2, Column 0
Mild
Row 2, Column 1
Moderate
Row 2, Column 2
Severe
Row 2, Column 3
None
Row 3, Column 0
Mild
Row 3, Column 1
Moderate
Row 3, Column 2
Severe
Row 3, Column 3
None
Row 4, Column 0
Mild
Row 4, Column 1
Moderate
Row 4, Column 2
Severe
Row 4, Column 3
None
Row 5, Column 0
Mild
Row 5, Column 1
Moderate
Row 5, Column 2
Severe
Row 5, Column 3
None
Row 6, Column 0
Mild
Row 6, Column 1
Moderate
Row 6, Column 2
Severe
Row 6, Column 3
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Section 9. Please rate each of these symptoms as you currently feel. Yes, some are repetitive but for good reason. Please do not "over think" these as you answer them. Remember, we are asking for YOUR answers. Please rate each of the following 24 medical conditions.
*
This field is required.
None
Mild
Moderate
Severe
Fatigue (Especially Evening)
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Cold Extremities
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Low Libido
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Dry Skin
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
General Aches/Pains
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Depression
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Scalp Hair Loss
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Brittle Nails
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Low Pulse Rate/Blood Pressure
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Memory Lapses
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Heart Palpitations
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Constipation
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Low Stamina
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Low Body Temperature
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Headaches
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Row 14, Column 3
Intolerance to Cold
Row 15, Column 0
Row 15, Column 1
Row 15, Column 2
Row 15, Column 3
Weight Gain
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
Row 16, Column 3
Anxiety
Row 17, Column 0
Row 17, Column 1
Row 17, Column 2
Row 17, Column 3
Swollen, Puffy Eyes
Row 18, Column 0
Row 18, Column 1
Row 18, Column 2
Row 18, Column 3
Decreased Swelling
Row 19, Column 0
Row 19, Column 1
Row 19, Column 2
Row 19, Column 3
Poor Concentration
Row 20, Column 0
Row 20, Column 1
Row 20, Column 2
Row 20, Column 3
High Cholesterol
Row 21, Column 0
Row 21, Column 1
Row 21, Column 2
Row 21, Column 3
Infertility
Row 22, Column 0
Row 22, Column 1
Row 22, Column 2
Row 22, Column 3
Fibromyalgia
Row 23, Column 0
Row 23, Column 1
Row 23, Column 2
Row 23, Column 3
Fatigue (Especially Evening)
Cold Extremities
Low Libido
Dry Skin
General Aches/Pains
Depression
Scalp Hair Loss
Brittle Nails
Low Pulse Rate/Blood Pressure
Memory Lapses
Heart Palpitations
Constipation
Low Stamina
Low Body Temperature
Headaches
Intolerance to Cold
Weight Gain
Anxiety
Swollen, Puffy Eyes
Decreased Swelling
Poor Concentration
High Cholesterol
Infertility
Fibromyalgia
None
Row 0, Column 0
Mild
Row 0, Column 1
Moderate
Row 0, Column 2
Severe
Row 0, Column 3
None
Row 1, Column 0
Mild
Row 1, Column 1
Moderate
Row 1, Column 2
Severe
Row 1, Column 3
None
Row 2, Column 0
Mild
Row 2, Column 1
Moderate
Row 2, Column 2
Severe
Row 2, Column 3
None
Row 3, Column 0
Mild
Row 3, Column 1
Moderate
Row 3, Column 2
Severe
Row 3, Column 3
None
Row 4, Column 0
Mild
Row 4, Column 1
Moderate
Row 4, Column 2
Severe
Row 4, Column 3
None
Row 5, Column 0
Mild
Row 5, Column 1
Moderate
Row 5, Column 2
Severe
Row 5, Column 3
None
Row 6, Column 0
Mild
Row 6, Column 1
Moderate
Row 6, Column 2
Severe
Row 6, Column 3
None
Row 7, Column 0
Mild
Row 7, Column 1
Moderate
Row 7, Column 2
Severe
Row 7, Column 3
None
Row 8, Column 0
Mild
Row 8, Column 1
Moderate
Row 8, Column 2
Severe
Row 8, Column 3
None
Row 9, Column 0
Mild
Row 9, Column 1
Moderate
Row 9, Column 2
Severe
Row 9, Column 3
None
Row 10, Column 0
Mild
Row 10, Column 1
Moderate
Row 10, Column 2
Severe
Row 10, Column 3
None
Row 11, Column 0
Mild
Row 11, Column 1
Moderate
Row 11, Column 2
Severe
Row 11, Column 3
None
Row 12, Column 0
Mild
Row 12, Column 1
Moderate
Row 12, Column 2
Severe
Row 12, Column 3
None
Row 13, Column 0
Mild
Row 13, Column 1
Moderate
Row 13, Column 2
Severe
Row 13, Column 3
None
Row 14, Column 0
Mild
Row 14, Column 1
Moderate
Row 14, Column 2
Severe
Row 14, Column 3
None
Row 15, Column 0
Mild
Row 15, Column 1
Moderate
Row 15, Column 2
Severe
Row 15, Column 3
None
Row 16, Column 0
Mild
Row 16, Column 1
Moderate
Row 16, Column 2
Severe
Row 16, Column 3
None
Row 17, Column 0
Mild
Row 17, Column 1
Moderate
Row 17, Column 2
Severe
Row 17, Column 3
None
Row 18, Column 0
Mild
Row 18, Column 1
Moderate
Row 18, Column 2
Severe
Row 18, Column 3
None
Row 19, Column 0
Mild
Row 19, Column 1
Moderate
Row 19, Column 2
Severe
Row 19, Column 3
None
Row 20, Column 0
Mild
Row 20, Column 1
Moderate
Row 20, Column 2
Severe
Row 20, Column 3
None
Row 21, Column 0
Mild
Row 21, Column 1
Moderate
Row 21, Column 2
Severe
Row 21, Column 3
None
Row 22, Column 0
Mild
Row 22, Column 1
Moderate
Row 22, Column 2
Severe
Row 22, Column 3
None
Row 23, Column 0
Mild
Row 23, Column 1
Moderate
Row 23, Column 2
Severe
Row 23, Column 3
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19
Are you taking a Biotin supplement?
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Yes
No
I don't know
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If so, how much Biotin are you taking?
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21
I am
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years old. I feel
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years old.
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I understand and agree that any information submitted will be stored in JotForm a HIPPA Certified company. JotForm will forward an email to our office alerting us that you have submitted the form. None of your private information will be transmitted via email.
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