Hormone Quiz Form

Body Comp

Select all that apply:

Unexplained weight gain

Difficulty losing weight

Losing muscle mass

Increase in cellulite

Increased belly fat (apple shape)

Brain/Mood

Select all that apply:

Feeling anxious or on edge

Brain fog or concentration issues

Loss of interest in sex

Feeling sad, blue, or depressed

Difficulty coping with stressful situations

Easily agitated or irritable

Uncontrollable mood swings

Female Issues

Select all that apply:

Vaginal dryness, discomfort

Heavy periods

Hot flashes/night sweats

Sore tender breasts

Painful sex

Fibriods or cysts

Gut

Select all that apply:

Belly feels bloated throughout the day

Frequent constipation

Always hungry or craving food

Craving sweets

Water retention or edema

Health

Select all that apply:

Have osteoporosis or osteopenia

Feel cold all of the time or have cold hands and feet

Dizzy upon standing

Sweating a lot

Tired all the time

Headaches or migraines

Trouble falling or staying alseep

Achy stiff joints

Skin/Hair/Nails

Select all that apply:

Hair thinning or falling out

Acne or oily skin

Nails are brittle, dry and easily break

Dry, flakey skin

Losing hair

Increased hair on face and body

Wrinkles, saggy skin

Hidden

Low E Total

Hidden

Low P Total

Hidden

Low T Total

Hidden

High T Total

Hidden

Adrenal Total

Hidden

Thyroid Total

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3 Minute Hormone Quiz

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