Client Hormone Assessment Form Hormone Assessment Date* Date Format: MM slash DD slash YYYY Name* First Last Email* A Low libido Insomnia Unexplained weight gain Painful and/or lumpy breasts Anxiety Headaches that occur before, during menstruation or ovulation Hot flashes Irregular menstrual cycle Total boxes from section A checked:B Vaginal dryness Night sweats Painful intercourse Memory problems Urinary tract infections Depression accompanied by lethargy Hot flashes Unexplained weight gain Mood Swings Trouble concentrating Skin changes -dry Bone loss Total boxes from section B checked:C Puffiness and bloating Breast tenderness Rapid weight gain Heavy bleeding Mood swings Migraine headaches Anxiety Brain Fog Insomnia Decreased sex drive Red flushing on your face Panic attacks New propensity to crying Fatigue Total number of boxes from section C checked:D Symptoms that are a combination of the symptoms in A and C E Irritability Problems sleeping Brain fog Low blood pressure Thin and/or dry skin Post Exercise Fatigue and/or muscle soreness Brown spots on face Unexplained weight gain/ Trouble losing weight Fatigue Hot flashes/night sweats Total boxes from section E checked:F ☐Hair loss? ☐Eyebrow and/or eyelash hair loss? ☐Weight gain despite diet and exercise? ☐Depression, anxiety and/or lethargy? ☐Flickering of the eyelids? Brittle and/or thinning hair, nails, and skin? Dry skin? High cholesterol? Muscle or joint pains and aches? Constipation? Tingling in your hands and/or feet? Cold hands and/or feet? Fatigue? Foggy brain (slow thoughts, hard to focus)? Infertility? Lower sex drive? A family history of thyroid problems Enlarged thyroid? Total boxes from section F FacebookInstagramEmail
