Hormonal Health Evaluation
Adrenal Glands
1. Stress seems to easily cause noticeable symptoms like flushing or heart palpitations
No
Mild
Moderate
Severe
2. Brain fog, forgetting basic things, a sense of mild confusion Stress seems to easily cause noticeable symptoms like flushing or heart palpitations
No
Mild
Moderate
Severe
3. Unexplained anxiety
No
Mild
Moderate
Severe
4. Low or high blood pressure
No
Mild
Moderate
Severe
5. Troubles falling asleep and/or wakes up after 2-4 hours of sleep and unable to fall back asleep within 30 minutes
No
Mild
Moderate
Severe
6. Alternating areas of pain, tenderness, hot, sore, and sen-sitive to the touch or diagnosed with chronic fatigue syn-drome or fibromyalgia
No
Mild
Moderate
Severe
Adrenal Glands %
Thyroid Gland
1. Hands and feet frequently feel cold or chilled
No
Mild
Moderate
Severe
2. Constantly feeling sleepy
No
Mild
Moderate
Severe
3. Feel slow-moving, sluggish
No
Mild
Moderate
Severe
4. Constipated regularly
No
Mild
Moderate
Severe
5. Dry or scaly skin
No
Mild
Moderate
Severe
6. Hair feels coarse and/or brittle
No
Mild
Moderate
Severe
7. Losing hair and/or outer third of eyebrow
No
Mild
Moderate
Severe
8. Heavy menstrual periods (men answer no)
No
Mild
Moderate
Severe
8. Weight gain despite changes in diet
No
Mild
Moderate
Severe
9. Take thyroid medication
No
Yes
Thyroid Gland %
Male Hormones
1. Decrease in muscle mass, with an increase in body fat
No
Mild
Moderate
Severe
2. Loss of sex drive
No
Mild
Moderate
Severe
3. Suffer from erectile dysfunction
No
Mild
Moderate
Severe
4. After 35 years of age started having troubles concentrating and/or lack of feeling sharp
No
Mild
Moderate
Severe
5. Unexplained depression and decreased since of wellbeing after 35 years of age
No
Mild
Moderate
Severe
Male Hormones %
Hormonal System Total (Male) %
Please list your top 5 complaints. If you don't have 5 that is okay.
1
2
3
4
5
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