Hormone Health Questionnaire

Date of Assessment

Date

Name

First InitialFirst 3 letters of last name

Date of Birth

Month-Day-Year

Somatotropin ( Growth Hormone)

	Never	Occasionally	Regularly	Very Very Often	Constantly
1.My hair is thinning
2 My cheeks sag
3. My gums are receeding
4. My abdome is flabby / I have a spare tire
5. My muscles are slack
6. My skin is thin and/or dry
7. It is hard to recover after physical activity
8. I feel exhausted
9. I don't like the world. I tend to isolate myself
10. I feel continuously anxious and worried

Somatotropin ( Growth Hormone) Score

Scoring: Overall total of 10 or less satisfactory. Between 11-20 possible somatotropin deficiency. 21 or more probable somatotropin deficiency.

DHEA

	Never	Occasionally	Regularly	Very Very Often	Constantly
1.My hair is dry
2. My skin and eyes are dry
3. My muscles are flabby
4. My belly is getting fat
5. I don't have much hair under my arms
6. I don't have much hair in the pubic area (0=plenty of hair / 4=none)
7.My body doesn't have much of a special scent during sexual arousal
8. I can't tolerate noise
9. My libido is low

DHEA Score

Scoring: Overall total of 10 or less satisfactory. Between 11-20 possible DHEA deficiency. 21 or more probable DHEA deficiency.

Thyroid

	Never	Occasionally	Regularly	Very Very Often	Constantly
1. I am sensitive to cold
2. My hands and feet are always cold
3. In the morning, my face is puffy and my eyelids are swollen
4. I put on weight easily
5. I have dry skin
6. I have trouble getting uo in the morning
7. I feel more tired at rest than when i am active
8. I am constipated
9. My joints are stiff in the morning
10. I feel like I am living in slow motion

Thyroid Score

Scoring: Overall total of 10 or less satisfactory. Between 11-20 possible thyroid deficiency. 21 or more probable thyroid deficiency.

Pregnenolone

	Never	Occasionally	Regularly	Very Very Often	Constantly
1. I have memory loss
2. My joints hurt (hands, wrists, elbows, feet, ankles, knees)
3. I'm feeling a bit drained and I have a hard time handling stress
4. I don't see colors as brightly as before
5. I have lost interest in art. I don;t appreciate art as much anymore
6.I don't have much hair under my arms or in the pubic area (0=plenty of hair / 4=none)
7. My muscles are flabby
8. I have abundant light-colored urine during the day
9. I have low blood pressure
10. I crave salty foods

Pregnenolone Score

Scoring: Overall total of 10 or less satisfactory. Between 11-20 possible pregnenolone deficiency. 21 or more probable pregnenolone deficiency.

Cortisol

	Never	Occasionally	Regularly	Very Very Often	Constantly
1. My face looks thinner
2. My friends call me skinny
3. I have eczema, psoriasis, urticaria (itchy rash), skin allergies, or other rashes
4. My heart beats quickly
5. My blood pressure is low
6. I crave salt or sugar (to the extent of bingeing)
7. I have digestive problems
8. I have allergies (hay fever, asthma, etc)
9. I am stressed out
10. I am easily confused

Cortisol Score

Scoring: Overall total of 10 or less satisfactory. Between 11-20 possible cortisol deficiency. 21 or more probable cortisol deficiency.

Testosterone (For Men and Women)

	Never	Occasionally	Regularly	Very Very Often	Constantly
1. My face has gotten slack and more wrinkled
2. I have lost muscle tone
3. My belly tends to get fat
4. I am constantly tired
5. I feel like having sex less often than I used to
MEN ONLY
7. My breast are getting fatty
8. I feel less self confident and more hesitant
9. My sexual performance is poorer than it used to be
10. II have hot flashes and sweats
11. I tire easily with physical activity

Testosterone Score

Scoring: For WOMEN: Overall total of 5 or less satisfactory. Between 6-10 possible testosterone deficiency. 11 or more probable testosterone deficiency. For MEN: Overall total of 10 or less satisfactory. Between 11-20 possible testosterone deficiency. 21 or more probable testosterone deficiency.

Melatonin

	Never	Occasionally	Regularly	Very Very Often	Constantly
1. I look older than I am
2. I have trouble falling asleep at night
3. I wake up during the night...
4. And I can't get back to sleep
5. My mind is busy with anxious thoughts while I am trying to fall asleep
6. My feet are too hot at night
7. When I get up, I do not feel rested
8.I feel like I am living out of sync with the world, going to bed late and waking up late
9. I can't tolerate jet lag
10. I smoke, drink, and/or use a beta-blocker or a sleep aid

Melatonin Score

Scoring: Overall total of 10 or less satisfactory. Between 11-20 possible melatonin deficiency. 21 or more probable melatonin deficiency.

Estrogen

	Never	Occasionally	Regularly	Very Very Often	Constantly
1. I am losing hairon top of my head
2. I am getting vertical wrinkles above my lips
3. My breast are droopy
4. My face is too hairy
5. My eyes are dry and easily irritated
6. I have hot flashes
7. I feel tired constantly
8. I am depressed
9. Women only: My menstrual flow is light (0=moderate, 1-3=low, 4=none
10. Women with periods: My cycles are irregular, too short (31 days)

Estrogen Score

Scoring: Overall total of 10 or less satisfactory. Between 11-20 possible estrogen deficiency. 21 or more probable estrogendeficiency.

Progesterone

	Never	Occasionally	Regularly	Very Very Often	Constantly
1. My breasts are large
2. My close friends complain that I am nervous and agitated
3. I feel anxious
4. I sleep lightly and restlessly
The following questions are for WOMEN who have not yet reached menopause & menopausal WOMEN who are taking hormone replacement therapy
5. My breasts are swollen and tender or painful before my period...
6. And my lower belly is swollen...
7. And I'm irritable and aggressive...
8. And I lose my self-control
9. I have heavy periods,,,
10. And they are continuously painful

Progesterone Score

Scoring: Postmenopausal women NOT treated with hormone replacement therapy: 4 or less satisfactory. Between 5 and 8 possibly progesterone deficiency. 9 or more probable progesterone deficiency. Menstrual women and women takinf hormone replacement therapy: 10 or more satisfactory. between 11-20 possible progesterone deficiency. 21 or more probable progesterone deficiency.

Hormone Assessment