Hormonal Imbalance Assessment
Name
*
First Name
Last Name
Email
*
example@example.com
Hormone Score
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Do you experience frequent mood swings, irritability, or anxiety?
*
Rarely
Sometimes
Frequently
How often do you feel excessively tired or fatigued, even after adequate sleep?
*
Rarely
Sometimes
Frequently
Have you experienced unexplained weight gain or difficulty losing weight?
*
Rarely
Sometimes
Frequently
Do you have irregular menstrual cycles (for women) or symptoms like erectile dysfunction (for men)?
*
Rarely
Sometimes
Frequently
How often do you experience digestive issues, such as bloating or constipation?
*
Rarely
Sometimes
Frequently
Do you feel unusually sensitive to cold or heat?
*
Rarely
Sometimes
Frequently
Have you noticed hair thinning, hair loss, or skin issues (acne, dryness)?
*
Rarely
Sometimes
Frequently
How often do you experience low libido or changes in your sex drive?
*
Rarely
Sometimes
Frequently
Do you have difficulty falling asleep or staying asleep?
*
Rarely
Sometimes
Frequently
Do you have frequent sugar cravings or feel hungry shortly after eating?
*
Rarely
Sometimes
Frequently
How often do you experience brain fog or difficulty concentrating?
*
Rarely
Sometimes
Frequently
Hormone Score
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