Do You Have A Hormone Imbalance?

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Full Name* This field is required.
First Name
Last Name
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E-mail* This field is required.
example@example.com
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Today's Date* This field is required.
Date
Month
Day
Year
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Age* This field is required.
5
What stage of menopause are you in?* This field is required.
Pre-menopause: No symptoms of perimenopause or menopause
Perimenopause: Estrogen is declining and you are experiencing irregular periods and other symptoms
Menopause: You haven't had a period for several months in a row
Post-menopause: You haven't had a period in 12 consecutive months
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If in post-menopause, how did this stage occur?
Naturally
Surgically-induced (partial or full hysterectomy)
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Have you been diagnosed with a hormone imbalance(s) or condition relative to your symptoms?:* This field is required.
Yes
No
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If "Yes," what is the imbalance or condition?
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What herbs, vitamins, supplements or medications are you taking? (If none, type "N/A.")* This field is required.
10
What hormonal birth control or HRT are you currently taking? (If none, type "N/A.")* This field is required.
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SYMPTOM GROUP 1* This field is required.Check as many symptoms you have experienced in the last 3-6 months (unless otherwise indicated.) In addition, check any symptoms you were experiencing prior to taking any current medications or HRT.
PMS (cramps, mood swings, etc.)
Insomnia
Early miscarriage* (ever experienced)
Painful and/or lumpy breasts
Increase in cellulite
Fluid retention/bloating
Cyclical headaches
Increased anxiety
Heart palpitations
Infertility* (ever experienced)
Night sweats
Foggy thinking
Panic attacks
Acne
None
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Progesterone Deficiency Symptom Total:
13
Progesterone Deficiency Score %
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SYMPTOM GROUP 2* This field is required.Check as many symptoms you have experienced in the last 3-6 months. In addition, check any symptoms you were experiencing prior to taking any current medications or HRT.
Vaginal dryness
Night sweats
Painful intercourse
Memory problems
Bladder infections
Lethargy/malaise
Depression
Hot flashes
Bone loss
Mood swings
Brain fog
Weight gain (especially in mid-section)
Incontinence
None
15
Low Estrogen Symptom Total:
16
Low Estrogen Score %
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SYMPTOM GROUP 3* This field is required.Check as many symptoms you have experienced in the last 3-6 months. In addition, check any symptoms you were experiencing prior to taking any current medications or HRT.
Cervical dysplasia (abnormal pap smear)
Breast tenderness
Rapid weight gain
Heavy periods/clotting
Fibroids
Mood swings
Red flush on face
Gallbladder problems
Weepiness
Food sensitivities
None
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Excess Estrogen Symptom Total:
19
Excess Estrogen Score %
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SYMPTOM GROUP 4Combination of Group 1 + Group 3
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Estrogen Dominance Symptom Total:(Sum of the Symptom Totals in Group 1 and Group 3)
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Estrogen Dominance Score %
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SYMPTOM GROUP 5* This field is required.Check as many symptoms you have experienced in the last 3-6 months. In addition, check any symptoms you were experiencing prior to taking any current medications or HRT.
Acne
Oily skin or hair
Polycystic Ovary Syndrome (PCOS)
Excessive hair on the face or arms
Hypoglycemia and/or unstable blood sugar (a good clue to these symptoms is whether you're a sugar junkie and/or get shaky when you don't eat regularly)
Thinning hair on the head
Scalp hair loss
Infertility* (ever experienced)
Ovarian cysts
Mid-cycle pain
Skin tags
Irregular/absent cycle
Irritability
None
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Elevated Androgens Symptom Total:
25
Elevated Androgens Score %
26
SYMPTOM GROUP 6* This field is required.Check as many symptoms you have experienced in the last 3-6 months. In addition, check any symptoms you were experiencing prior to taking any current medications or HRT.
Weight gain (especially around the midsection)
Cold hands and feet, or intolerance to cold/heat
Hair loss
Dry hair and/or skin
Sluggishness/fatigue
Slow heart rate
Thinning or papery skin
Muscle weakness
Eczema
Indigestion
Constipation
Enlarged thyroid
High cholesterol
Long recovery after activity
Moodiness
Slower metabolism
Diarrhea
None
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Under-active Thyroid Symptom Total:
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Under-active Thyroid Score %:
29
SYMPTOM GROUP 7* This field is required.Check as many symptoms you have experienced in the last 3-6 months. In addition, check any symptoms you were experiencing prior to taking any current medications or HRT.
Constant fatigue (especially in the morning when waking up or after exercise)
Feeling "wired" at night
Muscle weakness
Stress/low reserves for coping with stress
Slow metabolism and decreased thyroid function
Unexplained weight gain (especially in the midsection)
Racing heart
Anxiety/overwhelm
Insomnia
Low immunity (frequent bouts of the flu or upper respiratory infections)
Irregular menstrual cycles
Allergies and/or asthma
None
30
Elevated Cortisol Symptom Total:
31
Elevated Cortisol Score %
32
SYMPTOM GROUP 8* This field is required.Check as many symptoms you have experienced in the last 3-6 months. In addition, check any symptoms you were experiencing prior to taking any current medications or HRT.
Tiredness
Dizziness
Low blood pressure
Chronic inflammation
Joint pain
Problems falling asleep or staying asleep
Patches of darker skin
Salt or sugar cravings
Muscle cramps
Stomach pain
Low-grade depression
Getting a "second wind" in the evening
Problems with attention/concentration
Blood sugar issues
Weak nails or brittle hair
Tingling in the fingers
Difficulty losing weight
Shortness of breath
Impaired hearing or tininitus
Dry skin and puffiness in the face, hands and/or feet
Constipation
None
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Adrenal Fatigue Symptom Total:
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Adrenal Fatigue Score %
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SYMPTOM GROUP 9* This field is required.Check as many symptoms you have experienced in the last 3-6 months. In addition, check any symptoms you were experiencing prior to taking any current medications or HRT.
Irregular or missing periods
Weight gain/trouble losing weight (especially in mid-section)
Cystic acne
Hair growth on chin, above upper lip or on back, chest or stomach
Loss of scalp hair
Spotting between periods
Heavy bleeding and/or painful periods (now or before using hormonal birth control)
Ovarian cysts
Infertility/problems getting pregnant
Polycystic Ovary Syndrome (PCOS)
Depression
Anxiety
Tiredness
Insulin resistance (increased hunger and thirst, headaches, feeling hungry after meals, or high blood sugar levels in blood work)
None
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PCOS Symptom Total:
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PCOS Score %
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Highest Score %
39
Congratulations! You've completed the Hormone Symptoms Profile Assessment.

Note: The information contained in this assessment and your results are not intended to replace a one-to-one relationship with a qualified healthcare professional nor is it intended as medical advice.

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