Hormonal Imbalance Hormonal Imbalance Hormonal ImbalancePlease enable JavaScript in your browser to complete this form. - Step 1 of 3PART 1Are you running from task to task?YesNoDo you feel jittery, unfocused, or moody when hungry?YesNoAre you tired and wired?YesNoDo you have sugar cravings( dinner feels incomplete without something sweet)?YesNoDo you experience indigestion, acid reflux or ulcers?YesNoDo you struggle to calm down and slow down?YesNoDo you have pink or purple stretch marks on your belly or back? YesNoAre you quick to get angry?YesNoHave you experienced infertility or miscarriages?YesNoDo you have a hard time getting over adversity or diseases ?YesNoDo you experience hair loss?YesNoIs it hard for you to fall asleep and/or stay asleep ?YesNoDo you retain water (puffy face, fingers or feet)?)YesNoDo you have memory lapses, especially when emotional? YesNoDo you get frequent colds and flus?YesNoDo you experience heart palpitations?YesNoDo you have muffin top (a roll of body fat around your waistline? YesNoDo you have skin condition such as eczema or thinning skin?YesNoDo you have bone loss(osteopenia or osteoporosis)?YesNoTOTAL POINTS SCOREDPART 2Do you experience fatigue or burnout( do you have to use coffee to keep going)?YesNoDo you crave salt?YesNoDo you have low blood pressure?YesNo Do you feel dizzy after getting up from a seated or lying position? YesNoDo you see life and people in a negative way?YesNoDo you cry for no good reason or become easily emotional? YesNoDo you lose stamina, especially in the afternoon and evening?YesNoDo you have a hard time getting out of bed, or do you need two cups of coffee to wake up?YesNoHave your problem- solving skills decreased? YesNoHas your tolerance to stress decreased?YesNoDo you struggle to get over a simple cold, flu or infections? YesNoAre your blood sugar levels low or unstable?YesNoIs your sex drive lower?YesNoDo you feel mildly depressed?YesNoTOTAL POINTS SCOREDClick to ContinuePART 3Do you have headaches, especially around your period?YesNoHave you had ovarian cysts, breast cysts, or endometriosis? YesNoAre your legs itchy or restless, especially at night?YesNoHave you had any miscarriages during the first trimester?YesNoHave you experienced infertility or subfertility( you can’t hold on to pregnancy )?YesNoDo you have heavy or painful periods?YesNoDo you experience bloating, especially in the belly and ankle area, and /or water retention?YesNoAre your breasts ever painful and/or swollen?YesNoHave you had irregular periods and /or cycles that have become more frequent as you age?YesNoDo you have hot flashes?YesNoAre you irritable or anxious?YesNoDo you have difficulty falling and/or staying asleep? YesNoDo you have dry skin or skin that has lost its fullness?YesNoDo you experience spotting in the middle of your menstrual cycle?YesNoTOTAL POINTS SCOREDPART 4Do you have spider or varicose veins?YesNoDo you have any cellulite?YesNo Are your period’s heavy?YesNoHave you had breast or ovarian fibroids?YesNoDo you experience irritability, mood swings or anxiety?YesNoDo you get headaches or migraines, particularly before your period? YesNoAre you fat around your hips?YesNoDo you use birth control pills?YesNoHave you experienced heavy bleeding or post-menopausal bleeding?YesNoDo you experience bloating, puffing, or water retention?YesNoAre your breasts ever enlarged or do they feel tender? YesNoDo you have endometriosis or painful periods?YesNoDo you have PMS and/or depression?YesNoDo you sometimes cry for no good reasons? YesNoDo you have trouble falling asleep?YesNoDo you have gallbladder problems, or has your gallbladder been removed?YesNoTOTAL POINTS SCOREDPART 5Is your memory ever poor (‘why did I walk into this room?)?YesNoDo you have night sweats and/or hot flashes? YesNoIs your bladder leaky or overactive?YesNoDo you feel emotionally fragile, especially when compared to year agoYesNoDo you experience depression, anxiety, and/or lethargy (loss of enthusiasm)?YesNoDo you have trouble falling and staying asleep? YesNoDo your joints ache?YesNoHave you lost interest in exercise?YesNoDo you have bone loss or osteoporosis?YesNoHave you experienced vaginal dryness, irritation, or loss of feeling? YesNoAre your eyes, skin, and /or vagina dry?YesNoDo you have a low sex drive? YesNoIs sex painful?YesNoIs your skin dry and saggy? YesNoIs your skin thinning?YesNoAre your breasts shrinking and sagging? YesNoHave you experienced menopause?YesNoDo you have ‘love handles’ or fat gain around your abdomen?YesNoTOTAL POINTS SCOREDPART 6Do you have acne?YesNoDo you have oily skin and/or hair? YesNoHave you lost hair on your scalp?YesNoDo you have hair growth on your chin, upper lip, breasts, or stomach? YesNoHave you experienced infertility?YesNoAre your breasts shrinking and saggy?YesNoDo you experience irritability or aggression or get easily agitated? YesNoHave you gained fat around your belly?YesNoDo you experience irritability or aggression or get easily agitated? YesNoHave you gained fat around your belly?YesNoDo you have crave sweets and/or carbohydrates?YesNoDo you have fatty liver?YesNoAre your armpits discolored (darker and thicker skin than normal)?YesNoAre you hypoglycemic or hyperglycemic (low or high blood sugar levels)? YesNoDo you experience depression and/ or anxiety?YesNoDo you have ovarian cyst or PCOS?YesNoDo you experience pain in the middle of your menstrual cycle? YesNoAre you constantly hungry and/or has your appetite increased?YesNoTOTAL POINTS SCOREDPreviousClick to ContinuePART 7Have you experienced muscle loss?YesNoHave you experienced muscle weakness?YesNoHave you gained weight, especially ‘soft fat’ around the waist?YesNoHas your ratio of fat to muscle moved toward fat? YesNoDo you lack confidence compared with previously? YesNoDo you lack drive and assertiveness?YesNoIs your libido low? YesNoAre you tired?YesNoDo you experience mood swings, depression, and/ or low mood? YesNoDo you have difficulty concentrating?YesNoDo you have bone loss or osteoporosis? YesNoDoes your skin sag?YesNoHave you experienced hair loss?YesNoTOTAL POINTS SCOREDPART 8Have you lost any hair on your scalp?YesNoHave you lost any hair from your eyebrows and/or eyelashes? YesNoHave you gained weight despite a healthy diet and exercise? YesNoDo you experience depression, anxiety and/or lethargy?YesNoDo your eyelids flicker?YesNoAre your hair, nails, and skin brittle or thinning? YesNoIs your skin dry?YesNoDo you have high LDL cholesterol levels?YesNoDo you experience muscle or joint pains and caches? YesNoAre you feeling constipated?YesNoDo you feel tingling in your hands and/or feet? YesNoAre your hands and/or feet cold?YesNo Are you tired?YesNoDo you experience ‘foggy brain’ (slow, thoughts, difficulty focusing) Have you experienced infertility?YesNoIs your sex life lower than it was previously? YesNoIs your thyroid enlarged?YesNoDo you have a family history of thyroid problems? YesNoDo you have hives?YesNoAre there indents on the sides of your tongue when you stick it out?YesNoTOTAL POINTS SCOREDPART 9Do you still feel hungry even after a full meal? YesNoAre you tired after a meal?YesNoDo you crave sweets and carbohydrate all the time?YesNo Are you tired throughout the day?YesNoDo you experience extreme thirst or hunger?YesNoDo you experience frequent or increased urinations? YesNoDo you feel tingling sensations in your hands or feet?YesNoDo you have dark patches on the back of your neck, groin, and/or armpits (acanthosis nigricans )?YesNoHave you been diagnosed with type 2 prediabetes or diabetes? YesNoDo you have cardiovascular problems?YesNoHave you experienced vision changes and/or have you had cataracts? YesNoHave you experienced infertility or irregular periods?YesNoHave you experienced hair growth above the mouth or on the chin or nipples?YesNoDo you have high LDL cholesterol, high triglycerides or high blood pressure? YesNoHave you been diagnosed with fatty liver?YesNoIs your hemoglobin A1c (HA1c) sugar marker higher than 5.4percent? YesNoIs your insulin level higher than 15IU/ml?YesNoIs your fasting glucose level higher than 90mg/dL?YesNoTOTAL POINTS SCOREDPreviousSubmit