Female Hormone FormPlease set aside 5-10 minutes to fill out the form below. Note: this page DOES NOT autosave, please submit the form before exiting the tab. Name * First Name Last Name Email * Rate the following symptoms depending on the severity experienced. Please select none or leave blank if a symptom does not apply. Thyroid 1. Fatigue None Slightly Moderate Severe Extreme Depression None Slightly Moderate Severe Extreme Weight gain None Slightly Moderate Severe Extreme Cold intolerance None Slightly Moderate Severe Extreme Dry skin None Slightly Moderate Severe Extreme Anxiety None Slightly Moderate Severe Extreme Memory lapses None Slightly Moderate Severe Extreme Difficulty concentrating None Slightly Moderate Severe Extreme Muscle aches/stiffness None Slightly Moderate Severe Extreme Constipation None Slightly Moderate Severe Extreme Heavy periods None Slightly Moderate Severe Extreme Adrenal 2. Fatigue None Slightly Moderate Severe Extreme Allergies None Slightly Moderate Severe Extreme Muscle aches None Slightly Moderate Severe Extreme Decreased sex drive None Slightly Moderate Severe Extreme Decreased muscle mass None Slightly Moderate Severe Extreme Feeling cold None Slightly Moderate Severe Extreme Neck stiffness None Slightly Moderate Severe Extreme "Burned out" feeling None Slightly Moderate Severe Extreme Morning sluggishness None Slightly Moderate Severe Extreme Feeling unable to cope None Slightly Moderate Severe Extreme Irritable None Slightly Moderate Severe Extreme Tired but feeling wired None Slightly Moderate Severe Extreme Weight gain (waist) None Slightly Moderate Severe Extreme Impaired memory None Slightly Moderate Severe Extreme Loss of scalp hair None Slightly Moderate Severe Extreme Depression None Slightly Moderate Severe Extreme Low blood pressure None Slightly Moderate Severe Extreme Testosterone(Middle of the cycle) 3. Loss of sex drive None Slightly Moderate Severe Extreme Fatigue None Slightly Moderate Severe Extreme Vaginal dryness None Slightly Moderate Severe Extreme Decreased muscle mass None Slightly Moderate Severe Extreme Depression None Slightly Moderate Severe Extreme Difficulty concentrating None Slightly Moderate Severe Extreme Sleep disturbances None Slightly Moderate Severe Extreme Urinary incontinence None Slightly Moderate Severe Extreme Memory lapses None Slightly Moderate Severe Extreme Elevated cholesterol, insulin and/or blood pressure None Slightly Moderate Severe Extreme Estrogen(First ten days of cycle) 4. Night sweats None Slightly Moderate Severe Extreme Hot flashes None Slightly Moderate Severe Extreme Difficulty remembering None Slightly Moderate Severe Extreme Vaginal dryness None Slightly Moderate Severe Extreme Dry hair/skin None Slightly Moderate Severe Extreme Urine incontinence None Slightly Moderate Severe Extreme Urinary infections None Slightly Moderate Severe Extreme Painful intercourse None Slightly Moderate Severe Extreme Difficulty concentrating None Slightly Moderate Severe Extreme Depression None Slightly Moderate Severe Extreme Disturbed sleep None Slightly Moderate Severe Extreme Heart palpitations None Slightly Moderate Severe Extreme Progesterone(End of the cycle) 5. Fatigue None Slightly Moderate Severe Extreme Mood swings None Slightly Moderate Severe Extreme Depression None Slightly Moderate Severe Extreme Anxiety None Slightly Moderate Severe Extreme Irritability None Slightly Moderate Severe Extreme Tender breasts None Slightly Moderate Severe Extreme Irregular periods None Slightly Moderate Severe Extreme Fluid retention None Slightly Moderate Severe Extreme Loss of sex drive None Slightly Moderate Severe Extreme Less able to handle stress None Slightly Moderate Severe Extreme Cold body temperature None Slightly Moderate Severe Extreme Difficulty concentrating None Slightly Moderate Severe Extreme Headaches None Slightly Moderate Severe Extreme Weight gain (in hips) None Slightly Moderate Severe Extreme Heavy periods None Slightly Moderate Severe Extreme Androgens(End of the cycle) 6. Polycystic Ovary Syndrome (PCOS) None Slightly Moderate Severe Extreme Androgenic Alopecia None Slightly Moderate Severe Extreme Acne None Slightly Moderate Severe Extreme Ovulatory dysfunction None Slightly Moderate Severe Extreme Increase in body hair on face, chin & abdomen None Slightly Moderate Severe Extreme Decreased breast size None Slightly Moderate Severe Extreme Irregular periods or amenorrhea None Slightly Moderate Severe Extreme Thank you for your form submission. BACK TO ALL FORMS
