Hormone Check-up Form "*" indicates required fields Name* First Last Email* Phone*Age* Height* Weight* Over the last 6 monthsDo you currently or have you recently experienced…(please answer the questions to the best of your ability.)Section A* more trouble recovering from physical injury? GERD (Gastroesophageal reflux disease), indigestion, ulcers? Increased irritability, quickness to feel rage (screaming or yelling)? Disrupted sleep or trouble falling asleep? Sugar cravings, especially the need to have something sweet after eating a meal? Skin conditions, such as eczema or thinning skin? Feeling wired yet tired? High blood pressure or rapid heartbeat? Increased distractions, brain fog, or memory lapses? Difficulty winding down before bedtime or struggling with extra energy at bedtime? High blood sugar, insulin resistance, or feeling shaky between meals? Racing thoughts or feeling like you can’t slow down? Unexplained weight gain, especially around your midsection? Unexplained stretch marks on your back or belly? Section B* Unexplained crying or emotions? Feeling more stressed than usual? Exhaustion in the afternoons, typically between 2-5pm? Cravings for salty snacks? Excess sweating? Low blood pressure? Insomnia or difficulty sleeping, especially between 1-4am? Skin bruises easily? More negative point of view, almost an addiction? Hypotension (feeling dizzy when going from standing up to lying down)? Difficulty fighting infection or recovering from illness? Thyroid problems that may or may not have been treated? Heart palpitations or irregular heartbeats? Muscle weakness, muscle or joint pain? Low or unstable blood sugar? Increased or excessive sweating? Nausea, vomiting, diarrhea? Diarrhea alternating with bouts of constipation? Section C* PMS? Irregular menstrual cycles? Poor coordination? Miscarriage during the first trimester? Infertility? Polyps or cysts? Bloating before your period Hormonal headaches (migraines around menstrual cycles)? Sleep that is easily disrupted? Itchy legs, particularly at night? Heavy or painful periods? Section D* Rapid weight gain, especially in the hips, thighs, and butt? Fibroids? Irritability, increased mood swings, depression, and PMS symptoms? Endometriosis with painful periods? Increased weeping, sometimes for no reason at all? Breast tenderness? Anxiety? Brain fog or memory issues? Gallbladder issues (or removal)? Face has a red flush? Section E* Loss of interest in things you used to enjoy, especially exercise? Painful or achy joints, recent injuries, or bone loss? Sex has become painful? Increased bladder infections? Deepening skin wrinkles? Dryness (eyes, skin, vaginal area)? Low libido? Leaky or overactive bladder? Depression with alternating anxiety and lethargy? Middle of the night wakings? Hot flashes or night sweats? Section F* Depression and/or anxiety? Ovarian cysts? Pain in the middle of your cycle (around the second week, after ovulation)? Skin tags? Irritability or excessive rage or aggression? Discoloration in the armpits? Increased greasy skin or hair? Excess hair on face, arms, or chest? Unstable blood sugar? Thinning head hair? Infertility? PCOS? Section G Enlarged thyroid? Hair Loss, including eyelashes and eyebrows? Thinning, brittle fingernails? Dry hair, straw like, that tangles easily? Extra 20 pounds that you cannot lose? Family history of thyroid problems? Enlarged goiter? Difficulty swallowing? Heavy periods or other menstrual problems (cramping, diarrhea, constipation, pain)? Low libido? Sluggish reflexes? Frequent tingling in hands or feet? Muscle or joint pain? Cold hands and feet? Intolerant to cold or heat? Recurrent headaches? High cholesterol? Dry skin? Shiver more often than before? Always needing layers to keep warm? Increased lethargy? Decreased bowel movements or infrequent BM? Anxiety (with or without medication)? Slow heart rate? Slow speech or hoarse voice? EmailThis field is for validation purposes and should be left unchanged.
