Full Name:
Email Address:
Best Phone:	(xxx) xxx-xxxx or xxx-xxx-xxxx
	Estrogens
	How many hot flashes do you get per day?
SELECT 1 (Low) 2 3 4 5 6 7 8 9 10 (High)	What level of libido (sex drive) are you experiencing?
SELECT Yes No N/A (Male)	Are you experiencing any vaginal dryness? (female only)
SELECT Yes No	Are you experiencing any breast/pec or nipple tenderness?
SELECT Yes No	Are you experiencing any reduction in hair growth?
SELECT Yes No	Are you experiencing any hair loss?
SELECT Yes No	Are you experiencing excessive hair growth on your arms, chest or chin?
SELECT Yes No	Are you experiencing any feelings of depression?
SELECT Yes No	Are you experiencing any mood swings?
SELECT Yes No N/A (Male)	Are you experiencing any PMS symptoms? (female only)
	Testosterone
SELECT 1 (Low) 2 3 4 5 6 7 8 9 10 (High)	What level of libido (sex drive) are you experiencing?
SELECT Yes No	Are you experiencing any feelings of aggression?
SELECT 1 (Low) 2 3 4 5 6 7 8 9 10 (High)	What overall level of energy are you experiencing?
	Adrenals
SELECT Yes No	Are you experiencing any night sweats?
SELECT Yes No	Are you having trouble falling asleep at night?
SELECT Yes No	Are you having trouble staying asleep at night?
	How many times do you wakeup during the night?
SELECT Yes No	Do you have extra fat around your mid-section?
SELECT Yes, Gaining Yes, Losing No, Staying Steady	Are you experiencing any weight gain or loss?
SELECT Yes No	Are you experiencing any headaches?
SELECT Yes No	Are you experiencing any cravings for salt?
SELECT Yes No	Are you having trouble staying focused (brain fog)?
SELECT Yes No	Are you experiencing short-term memory loss?
SELECT Yes No	Are you experiencing any unexplainable feelings of anxiety?
SELECT Yes No	Are you experiencing any allergic reactions? If Yes, please describe:
	Thyroid
SELECT 1 (Low) 2 3 4 5 6 7 8 9 10 (High)	At 8AM, what energy level do you have?
SELECT 1 (Low) 2 3 4 5 6 7 8 9 10 (High)	At 12PM, what energy level do you have?
SELECT 1 (Low) 2 3 4 5 6 7 8 9 10 (High)	At 4PM, what energy level do you have?
SELECT 1 (Low) 2 3 4 5 6 7 8 9 10 (High)	At 8PM, what energy level do you have?
SELECT Yes No	Are you experiencing any reduction in hair growth?
SELECT Yes No	Are you experiencing any hair loss?
SELECT Yes No	Are you experiencing excessive dry skin?
SELECT Yes No	Are you experiencing any heart palpitations?
SELECT Yes No	Are your nails brittle or thinning?
SELECT Yes No	Are you experiencing any malaise (fatigue)?
SELECT Yes No	Are you experiencing any unexplainable cold flashes/spells?
SELECT Yes No	Are you experiencing any unexplainable hot flashes/spells?
SELECT Yes No	Do you have a family history of Thyroid?
	Yeast
	How many times do you urinate each day?
SELECT High (Must Go Right Then) Medium Low (It Can Wait)	When you get the urge to urinate, what level of urgency do you feel?
SELECT Yes No	Are you experiencing any feelings of being bloated?
SELECT Yes No	Are you experiencing any intestinal discomfort?
SELECT Yes No	Are you experiencing any flatulence (gas)?
SELECT Yes No	Do you have a white coating on your tongue?
SELECT Yes No	Are you experiencing any cravings for carbs?
SELECT Yes No	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:
	Prescriptions (Rx)
	List all the prescriptions you are taking and describe how you are taking each: # Drug Dosage (How you are currently taking) 1) 2) 3) 4) 5) 6) 7) 8) 9) 10)
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