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
No
Mild
Moderate
Severe
9. Weight gain despite changes in diet
No
Mild
Moderate
Severe
10. Take thyroid medication
No
Yes
Thyroid Gland %
Women Hormones
1. Anxious, irritable, aggressive or hostile
No
Mild
Moderate
Severe
2. Breast tenderness, swelling
No
Mild
Moderate
Severe
3. Being easily overwhelmed, sad, excessively irritable or ir-rational
No
Mild
Moderate
Severe
4. Abnormally heavy or scanty flow, pain with cycle, periods occur irregulary or absent (not in menopause), diagnosed with fibroids, endometresosis, ovarian cysts or fibroids
No
Mild
Moderate
Severe
5. Pain when you ovulate
No
Mild
Moderate
Severe
6. Menstrual blood is dark and clots are present
No
Mild
Moderate
Severe
7. Troubles getting pregnant
No
Mild
Moderate
Severe
8. Sexual intercourse is uncomfortable
No
Mild
Moderate
Severe
9. Increased growth of dark facial and/or body hair
No
Mild
Moderate
Severe
10. Interest in having sex is low
No
Mild
Moderate
Severe
11. Had a hysterectomy, uterine ablations, D&C for heavy bleeding
No
Mild
Moderate
Severe
12. Hot flashes or spontaneous sweating
No
Mild
Moderate
Severe
Female Hormones %
Hormonal System Total (Female) %
Please list your top 5 complaints. If you don't have 5 that is okay.
1
2
3
4
5
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