Hormone Assessment - Existing Patients

* = Required Fields

Prescriptions (Rx)

List all the prescriptions you are taking and describe how you are taking each: DrugDosage (How you are currently taking)

Estrogens

Are you answering this questionnaire for the yearly hormone testing?
Are you pre/postmenopausal? (female only)
If you are premenopausal, on what day of the month did you begin the urine collection? (female only)
How many hot flashes do you get per day?
What level of libido (sex drive) are you experiencing?
Are you experiencing any vaginal dryness? (female only)
Are you experiencing any breast/pec or nipple tenderness?
Are you experiencing any reduction in hair growth?
Are you experiencing any hair loss?
Are you experiencing excessive hair growth on your arms, chest or chin?
Are you experiencing any feelings of depression?
Are you experiencing any mood swings?
Are you experiencing any PMS symptoms? (female only)

Testosterone

Adrenals

Thyroid

Yeast

How many times do you urinate each day?
When you get the urge to urinate, what level of urgency do you feel?
Are you experiencing any feelings of being bloated?
Are you experiencing any intestinal discomfort?
Are you experiencing any flatulence (gas)?
Do you have a white coating on your tongue?
Are you experiencing any cravings for carbs?
Are you experiencing any itching on or around your ears, eyes, nose or other areas?

Other Symptoms

List any other symptoms that you are experiencing which were not covered above: