(813) 671-7570
Name:
Email:
Physician:
Symptoms
Never1
Mild2
Moderate3
Severe4
1. Decline in general well being 1234
2. Joint pain/muscle ache 1234
3. Excessive sweating/hot flashes 1234
4. Sleep problems 1234
5. Increase need for sleep 1234
6. Irritability 1234
7. Nervousness 1234
8. Anxiety 1234
9. Depressed mood 1234
10. Exhaustion/laking vitality 1234
11. Declining metal ability/focus/concentration 1234
12. Decreased muscle strength 1234
13. Weight gain/belly fat/inability to lose weight 1234
14. Breast tenderness 1234
15. Rapid hair loss 1234
16. Migraine headaches 1234
17. Decreased desire/libido 1234
18. Decreased ability to perform sexually/climax 1234
19. Dry skin 1234
20. Cold all of the time 1234
21. Constipation 1234
22. White spots on nails 1234
23. Bruise easily 1234
24. Loud noises bother me 1234
25. Frequent heartburn 1234
0 - 25Fairly Healthy
25 - 50Hormonal Imbalance is Beginning
50 and aboveHormonal Deficiency/ Deficient in Nutrients
* Scores of 25 or higher: Blood tests strongly recommended
Total Number
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