For Women

Use each of the following checklists to determine your patients’ symptoms of hormone imbalance and to help you choose the appropriate hormone test profile.

Category 1:  Basic Hormone Imbalance

Mark which of the following symptoms are troublesome and/or persist over time.

 Hot flashes	 Mood swings (PMS)	 Urinary incontinence	 Night sweats
 Heart palpitations	 Cystic ovaries	 Vaginal dryness	 Acne
 Heavy menses	 Foggy thinking	 Weight gain	 Depressed mood
 Fibrocystic breasts	 Irritability	 Increased body/ facial hair	 Headaches
 Thinning skin	 Uterine fibroids		 Bone loss

Number selected: ____

Category 2:  Adrenal Hormone Imbalance 

Mark which of the following symptoms are troublesome and/or persist over time.

 Aches and pains	 Elevated triglycerides	 Morning fatigue	 Bone loss
 Sleep disturbances	 Depression	 Anxiety	 Blood sugar imbalance
 Infertility	 Nervousness	 Allergic conditions	 Autoimmune illness
 Chronic illness	 Evening fatigue	 Susceptibility to infections

Number selected: ____

Category 3: Thyroid Hormone Imbalance

Mark which of the following symptoms are troublesome and/or persist over time.

 Aches and pains	 Anxiety	 Brittle nails	 Depression
 Dry skin	 Cold hands and feet	 Headaches	 Infertility
 Fatigue	 Foggy thinking	 Weight gain	 Feeling cold all the time
 Heart palpitations	 Low libido	 Inability to lose weight	 Sleep disturbances
 Constipation	 Thinning hair	 Menstrual irregularities	 Elevated cholesterol

Number selected: ____