• Recheck Paperwork

    Recheck Paperwork

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  • Part 1

  • INSTRUCTIONS: Check the number which best describes the intensity of your symptoms for the past 3 months. If you don't know the answer to a question, leave it blank. (0 for symptom not present, 1 for Mild, 2 for Moderate, 3 for Severe)

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  • If you have checked 2 or more boxes in this group, find out what type of hormonal imbalance you may have below.


    1. SYMPTOM GROUP 1 Progesterone deficiency: This is the most common hormone imbalance among women of all ages. You may need to change your diet, ask your doctor about getting off of synthetic hormones and you may need to use some progesterone cream.

  • If you have checked 2 or more boxes in this group, find out what type of hormonal imbalance you may have below.


    2. SYMPTOM GROUP 2 Estrogen deficiency: This hormone imbalance is most common in menopausal women; especially if you are petite and/or slim. You may need to make some special changes to your diet; take some women's herbs; and some women may even need natural estrogen.

  • If you have checked 2 or more boxes in this group, find out what type of hormonal imbalance you may have below.


    3. SYMPTOM GROUP 3 Excess estrogen: In women, this is most often solved by getting off of the conventional hormones (with your primary care physician's approval) most often prescribed by doctors for menopausal women.

  • If you have checked 2 or more boxes in this group, find out what type of hormonal imbalance you may have below.


    4. SYMPTOM GROUP 4 Estrogen dominance: This is caused when you don't have enough progesterone to balance the effects of estrogen. Thus, you can have low estrogen, but if you have even lower progesterone you may experience symptoms of estrogen dominance. Many women between the ages of 40 and 50 suffer from estrogen dominance.

  • If you have checked 2 or more boxes in this group, find out what type of hormonal imbalance you may have below.


    5. SYMPTOM GROUP 5 Excess androgens (male hormones): This is most often caused by too much sugar and simple carbohydrates in the diet and is often found in women who have polycystic ovary syndrome (PCOS)

  • If you have checked 2 or more boxes in this group, find out what type of hormonal imbalance you may have below.


    6. SYMPTOM GROUP 6 Cortisol deficiency: this is caused by tired adrenals, which is usually caused by chronic stress or chronic inflammation.

  • Our Recommended Adrenal Function Test: DUTCH COMPLETE

    Combining advanced hormone testing and nutritional support, Dried Urine Testing for Comprehensive Hormones (DUTCH)

    The most advanced test for sex and adrenal hormones.

    More comprehensive than serum, saliva or 24-hour urine testing
    Easy patient collection (4 dried urine samples collected simply on filter paper)
    Unparalleled adrenal testing (diurnal free cortisol pattern with cortisol metabolites)
    Accurate and comprehensive testing of sex hormones and metabolites (including 2,4,16-OH estrogens)
    Effective monitoring of hormone replacement (improved clinical accuracy for many scenarios)
    8 separate lab methods (GC-MS/MS, LC-MS/MS) to ensure the most accurate methods for each test
    One simple test to bring you unrivaled clinical information and confident clinical conclusions
    DUTCH testing allows providers to make the most informed clinical decisions about treatment options. Precision Analytical has raised the bar on lab testing with DUTCH.

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  • Part 13B (Sleep Apnea)

    Sleep apnea is a common disorder. Experts say it affects about eighteen million Americans. People with sleep apnea stop breathing for brief periods while they sleep. They may awaken for a few seconds as they struggle to breathe. The next day, the sleeper may not remember what happened. Signs of the disorder include sleepiness during the day and restless sleep. Some people make rough sounds while they sleep. More men have sleep apnea than women do. It is also common in older adults and in persons who are heavy

  • If you circled 5 or more symptoms, you could have OSA (obstructive sleep apnea). The risks of OSA include heart attacks, strokes, impotence, irregular heartbeat, high blood pressure and heart disease.

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  • 1.1 CURRENT DENTAL FILLINGS (if you're not sure, please ignore)

  • Amalgam

  • Gold

  • Titanium

  • Composites

  • Metal-bond ceramic

  • Cobalt-crown

  • Non-metallic ceramic

  • 1.2 ROOT CANAL FILLINGS

  • Amalgam

  • Gutta Percha

  • Calcium Hydroxide

  • Other

  • Gene HAQ

  • Should be Empty: