Hormone Balancing Quiz for Women
How frequently do you experience the following symptoms?
Fatigue
*
Never
Mild
Moderate
Severe
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Memory Loss/Confusion
*
Never
Mild
Moderate
Severe
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Decreased Sex Drive/Libido
*
Never
Mild
Moderate
Severe
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Mood Changes/Irritability
*
Never
Mild
Moderate
Severe
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Sleeping Problems
*
Never
Mild
Moderate
Severe
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Next
Vaginal Dryness
*
Never
Mild
Moderate
Severe
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Next
Weight Gain/Bloating
*
Never
Mild
Moderate
Severe
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Hot Flashes/Night Sweats
*
Never
Mild
Moderate
Severe
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Symptoms of Hair Loss
*
Never
Mild
Moderate
Severe
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Next
Joint Pain Or Other Chronic/Acute Pain
*
Never
Mild
Moderate
Severe
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Next
Cold All The Time
*
Never
Mild
Moderate
Severe
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Next
Urinary Incontinence
*
Never
Mild
Moderate
Severe
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Next
Acne Scarring or Sunspots
*
Never
Mild
Moderate
Severe
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Hair Loss
*
Never
Mild
Moderate
Severe
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Next
Family History of Heart Disease
*
Yes
No
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Family History of Osteoporosis
*
Yes
No
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Family History of Breast Cancer
*
Yes
No
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Family History of Breast Cancer
*
Yes
No
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Family History of Alzheimer's Disease
*
Yes
No
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Full Name
*
Email
*
Phone
*
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