Female Hormonal Health Assessment

Your Name

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Email

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Phone Number

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What's the main thing you're looking to improve with taking this assessment?

How to Take the Assessment:

For the questions below you will see that each question/symptom has 4 boxes to choose from. What you're going to do is mark as you feel each symptom.

For the boxes that have ”**” and say (Yes/No)

Leave these blank if your answer is "No". Hit the first "Yes" box if your answer is "Yes" (Yes will give you a score of 3)

If you're using your phone it's best to hold it in Landscape (Sideways) to view it more effortlessly... As shown below.

Disclaimer: This test will not give medical advice, it will not diagnose, cure or treat diseases. All information from this is to be taken and followed at your own risk. The results are not solid evidence of imbalances. It’s meant to be used as a guide to help you pick the best lab test for your symptoms.

Imbalance #1: Low Progesterone Self-assessment. (Leave blank If you don't experience the symptom)

	Yes/No. Yes = 3	Daily =3	Weekly = 2	Monthly = 1
Low mood or depression
Weight gain
Tender breast
Low libido
PMS (Yes/No)
Missed periods (Yes/No)
Insomnia (Yes/No)
Infertility (Yes/No)
Hair loss (Yes/No)
Spotting in the second half of your cycle (Yes/No)
Miscarriage(s) (Yes/No)
Endometriosis(Yes/No)
Low or no signs of ovulation (Yes/No)

Calculation: Scoring 0-39. 0 -10 = Likely not low, 10-20 = a chance it's low, over 20 = very likely to be low. Note: Low progesterone in the mid-luteal peak (Days 19-22) causes estrogen dominance (ED) as ED is calculated with the ratio of progesterone and estrogen on days 19-22

Imbalance #2: High Estrogen Self-assessment. (Leave blank If you don't experience the symptom)

	Yes/No. Yes = 3	Daily =3	Weekly = 2	Monthly = 1
Painful periods (Yes/No)
Menstrual cycles under 21 days (Yes/No)
High amounts of fluid retention
Tender breast
Menstrual migraines
Varicose veins (Yes/No)
Using estrogen-containing birth control (Yes/No)
Weight gain around the hips (Yes/No)
Endometriosis (Yes/No)
Unstable Blood sugar
Recurring yeast infections
Bloating (Not just from food)

Calculation: Scoring 0-36. A score of 0-10 = Estrogen not high, 10-20 = Elevated estrogen likely, 20-36 = High estrogen very likely

Imbalance #3: High Testosterone Self-assessment. All are Yes or No questions. (Only seen Elevated in 10-15% of women's labs) (Leave blank If you don't experience the symptom)

	Yes/No. Yes = 3
Irregular periods
Hair in uncommon places
Acne/skin breakouts
PCOS
High LDL (Bad) cholesterol
Aggressive outbreaks

Calculation: Scoring 0-18. 0-3 = No issues, 3-9 = High T Likely, 9-18 = High T very likely.

Imbalance #4: Low Testosterone Self-assessment. (Leave blank If you don't experience the symptom)

	Yes/No. Yes = 3	Daily =3	Weekly = 2	Monthly = 1
Nervousness
Low confidence
Low libido (sex drive)
Osteoporosis (Yes/No)
Decreased strength
Muscle loss (in the past year) Yes/No)
Vaginal dryness
Low recovery ability
Fatigue
Brain fog

Calculation: Scoring 0-30. 0-6 = No issues, 6-15 = Low T slightly likely, 15-30 = Low T very likely.

Imbalance #5: Low Thyroid (hypothyroidism) Self-assessment (High Thyroid hyperthyroidism is less common, and If you have extreme weight loss and/or irregular heartbeat would be signs) (Leave blank If you don't experience the symptom)

	Yes/No. Yes = 3	Daily =3	Weekly = 2	Monthly = 1
Weight gain without changing diet (Yes/No)
Inability to lose weight even on a restricted diet (Yes/No)
Brittle nails (Yes/No)
Loss of the outer third of eyebrows (Yes/No)
History of Postpartum Depression (Yes/No)
History of miscarriage(s) (Yes/No)
Feeling cold (Even in warm areas)
Puffiness around eyes
Constipation
Low mood or anxiety
Poor memory or concentration
High levels of Fatigue

Calculation: Scoring 0-36. 0-10 = No issues, 10-20 = Low Thyroid slightly likely, 20-26 Low Thyroid very likely

Imbalance #5: High Cortisol/HPA Alarm stage Self-assessment. Note: We recommend that every client gets their cortisol checked at some point as we do at a 4-point cortisol across the day to ensure that your body is producing cortisol at the right amounts during the right times of the day. This way we can see your natural diurnal rhythm. With this also The HPT has 7 stages of disfunction the last/worst being low/no cortisol so high cortisol is not the only bad thing.

	Yes/No. Yes = 3	Daily =3	Weekly = 2	Monthly = 1
Tired all day then awake at night (after 10 pm) (Yes/No)
Muffin top fat gain (Yes/No)
PCOS (Yes/No)
Autoimmune issues (Yes/No)
Frequent colds or illnesses (Yes/No)
High blood pressure (hypertension) (Yes/No)
High blood sugar (hyperglycemia) (Yes/No)
Menopausal symptoms
Feeling Overwhelmed
Needing coffee to get through your days
Insomnia
Waking during the night
Waking up tired even after 8+ hours in bed
Trouble falling asleep
Low sex drive
Tired after meals that contain carbs
Stressed
Feeling burnt-out
Irritability
Fluid retention (Ankles, wrists, or hands)

Calculation: Scoring: 0-60. 0-15 = No issues, 15-30 = a chance for issues, 30-40 = very likely high, 40+ = High

If you have any past bloodwork, at home labs, or related test you can upload for review.

	Yes/No. Yes = 3	Daily =3	Weekly = 2	Monthly = 1
Low mood or depression
Weight gain
Tender breast
Low libido
PMS (Yes/No)
Missed periods (Yes/No)
Insomnia (Yes/No)
Infertility (Yes/No)
Hair loss (Yes/No)
Spotting in the second half of your cycle (Yes/No)
Miscarriage(s) (Yes/No)
Endometriosis(Yes/No)
Low or no signs of ovulation (Yes/No)

	Yes/No. Yes = 3
Irregular periods
Hair in uncommon places
Acne/skin breakouts
PCOS
High LDL (Bad) cholesterol
Aggressive outbreaks