3. Male? 4. Hydrocortisone (or derivates)? 5. Other? Vitamins/minerals/trace elements: How are you doing? very well well average not well very bad
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1 LAUREN CIEL SWERDLOFF MD INCORPORATED 1821 WILSHIRE BLVD. SUITE # 220 SANTA MONICA, CA (310) FAX: (310) Could you please fill in this questionnaire and bring it at the next appointment? Your answers will enable us to help you better. DATE : NAME : How are you doing? very well well average not well very bad Improvements since last consultation?. Complaints? Since last consultation : Did you undergo : A surgery? An accident? Severe stress? If yes, which one(s)?.. when?.. Your present treatment (of the last weeks)? : Hormones : 1. Thyroid? 2. Female? 3. Male? 4. Hydrocortisone (or derivates)? 5. Other? Vitamins/minerals/trace elements: Other treatments? no yes - if yes,which ones? MEDICATION DAILY DOSAGE
2 How is your present medical condition? Please fill in the cases which closely correspond to your present medical condition (fill in one case per symptom) (If you are out of time, fill in at least the questions marked in bold). No Few Moderately A lot Very much Never Sometimes Regularly Often Always I. Thyroid hormones : 0 ± Excessive sensitivity to cold? Cold feet? 2. Fatigue in the morning? 3. Depressed? 4. Slowness? 5. Headaches? 6. Swollen eyelids (especially in the morning)? Swollen hands and feet? 7. Constipation? 8. Muscle cramps in feet/calves at night? 9. Stiff joints when getting up in the morning? 10. Dry skin? 11. Diffuse loss of hair? 12. Colds and flu? 13. Sore throat? 1. Tachycardia (quick heart beats)? 2. Abnormal nervousness (with inner trembling)? 3. Excessive heat sensation? 4. Excessive sweating? 5. Excessive thirst? 6. Excessive hunger? 7. Weight loss? 8. Trembling of fingers? II. Cortisol 1. Poor resistance to stress? 2. Abnormal fatigue after stress? 3. Low blood pressure? 4. Dizziness? 5. Empty, drowsines head? 6. Moments of energy loss during the day? 7. Sugar or sweet cravings? 8. Salty food craving? 8. Lack of appetite? 9. Allergies? 10. Asthma? 11. Joint pain in the : - Upper body, where?. - Lower body, where?.. 1. Swollen face (like a balloon)? 2. Euphoric? 3. Agitation?
3 III. DHEA 1. Axillary and pubic hair growth? IV. Aldosterone 1. Feeling better when laying down on bed? 2. Need to quickly urinate after drinking? 3. Swollen feet? 4. High blood pressure? V. Sexual hormones 1. Permanent fatigue (the whole day)? 2. Wrinkles : - at the corner of the eyes? - in the handpalms? 3. Hot flushes? Night sweats? 4. Being out of breath? 5. Heart pain during exercise or after stress? VI. Male hormones 1. Easy bruises? 2. Decreased muscular strength? 3. For adults : - decreased libido (sexual desire)? - reduced sexual potency? 1. Excessive agressivity / dominant character? 2. Oily skin? 3. Greasy hair? 4. Acne? 5. Excessive body hair? VII. Oestrogens 1. Hair loss on top of the head? 2. Dry eyes For women : - droopy breasts? - dry vagina? - excessive body hair growth? - are you still menstruating? yes no - irregular periods? no short cycles too long cycles (27-31j.) (26 j. or less) (32 j. or more) - painful menses, with heavy cramps? - depression before menstruation?
4 VIII. Progesterone - Constant painful menstruation? - Heavy blood loss? - Painful, swollen breast before the periods? - Nervous, irritable, anxious? IX. Melatonine 1. Light, anxious, agitated sleep? 2. Trouble falling asleep? 3. Anxious thoughts at night 4. Excessive need for sleep? 5. Deep, excessively prolonged sleep? 6. Deep sleep during 3 to 4 hours, but getting up to early, and having a heavy head in the morning I. Growth hormone 1. Thin hair or thinner than before? 2. Thin skin? 3. Sagging cheeks? 4. Retracted gums? 5. Aging body? 6. Low back pain? 7. Decreased abdominal tone? 8. Droopy inner side of legs? 9. Cellulite? 10. Low quality of life? 11. Quickly tired at exercise? 12. Difficult recovery after exercise? 13. Excessive emotional sensitivity? 14. Permanent anxiety? 15. Tendency to isolate yourself at home? 16. Lack of appetite for meat? 1. Swollen feet? 2. Too much muscle mass? 3. Tingling fingers? NUTRITION : Coated tongue? Difficult digestion? Swollen higher belly? Swollen lower belly? Diarrhea? Constipation?
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