Estrogen Self Test. Check yes if you experience the associated low estrogen symptom.

Similar documents
The Mac Protocol. Hormone Self Test. Check yes or no if you experience the symptoms listed below each hormone. Estrogen. Symptom Yes No.

HORMONAL LEVELS SELF TEST. Date Full Name No.

Hormone Deficiency Tests

Extreme Deficiency. Never. 1. I look older than I am I have trouble falling asleep at night

! 30 E Padonia Rd, #305, Timonium, MD Phone: (410) Fax: (443)

HORMONES AND YOUR HEALTH Charlie Tucker Pharm. D

Bodily Conditions Rooted in Hormone Imbalance

Name: Date of Birth: Age: Address: City State Zip

THE MANY SYMPTOMS ROOTED IN HORMONE IMBALANCES

Hormone. for Women. Dr. Melanie MacIver, ND

THE HORMONE HEALTH PROFILE

We acknowledge the commitment you are making to your health and your

Medications/Supplements/Vitamins/Herbs currently taking regularly

Metabolic Assessment Form

1405 NE Douglas Lee s Summit, MO Phone: Date: Fax: Female Information and Health Summary

Accession #: Patient: Jane Doe Convert to pdf, Save or PRINT >> ADRENAL CHECK

Why do I need any hormone replacement? What is Menopause? What symptoms are treated by estrogen Injections?

8605 SW Creekside Place Beaverton, OR Phone: Fax: Height 5 ft 8 in BMI Weight 154 lb

Kimberley A. Schroeder, D.O. 115 Baker Drive Tomball, TX

Balancing Hormone Function in Women By Meghna Thacker, NMD

TEST REPORT # SB. Patient Name: Comprehensive Male Profile I Patient Phone Number: TEST NAME RESULTS 08/12/18 RANGE

Dr Cara Flamer GSH Medical 801 Eglinton Ave West, Suite 100 Toronto, ON

PRNRX COMPOUNDING PHARMACY

3. Male? 4. Hydrocortisone (or derivates)? 5. Other? Vitamins/minerals/trace elements: How are you doing? very well well average not well very bad

MenoChat. City State Zip Code. Employer Job Title. Primary Care Provider Phone: History. Desired Outcome:

8605 SW Creekside Place Beaverton, OR Phone: Fax: Samples Collected. Samples Received 06/21/2017

FEMALE SYMPTOM QUESTIONNAIRE

Female Patient Questionnaire & History

Hormone Consultation for Women

Female Patient Questionnaire & History

Balancing Female Hormones

Test Results SB Samples Arrived: 01/15/2014 Samples Collected: Saliva: 01/11/14 07:14 Date Closed: 01/18/2014

Female New Patient Package

ANTI-AGING HORMONE BALANCING WEIGHT LOSS NUTRITION

Date of Birth: Age: Gender: M F. Race/Ethnicity: American India Asian African American White Hispanic Other

Female New Patient Package

Meet Micki Contini, MS CNC

You may also fax, , or bring it to office ahead of time, but please bring another paper copy with you at the time of visit.

TEST REPORT # U. Patient Name: Sleep Balance Patient Phone Number: TEST NAME RESULTS 07/30/18 RANGE

Neuroendocrine Evaluation

Free Report: How Your Hormones Can Make You Overweight and Miserable

Ohio Northern University HealthWise. Authors: Alexis Dolin, Andrew Duska, Hannah Lamb, Eric Miller, Pharm D Candidates 2018 May 2018

All nutrition appointments NOT given 24 hours notice of cancellation will incur a $50 charge.

Female New Patient Package

TOUCHMATTERS MANUAL THERAPY Health History Form NAME: DATE: ADDRESS: (street and number) (city) (postal code) TELEPHONE: (home) (work) (cell)

By J. Jayasutha Lecturer Department of Pharmacy Practice SRM College of Pharmacy SRM University

My energy is lower than I would like it to. I feel exhausted after exercising or physical activity.

INSURANCE DISCLAIMER

Symptom Review (page 1) Name Date

Nutrition Questionnaire

What do you believe is causing your most important health concern?

DHATU ASSESSMENT. Total the number of symptoms for each tissue category. 1. BLOOD PLASMA (RASA). The clear, serum portion of the blood.

Pure Health Natural Medicine

Wellness on the Mountain ~UR Healing Connection Today's Date Name

Menopause and HIV. Together, we can change the course of the HIV epidemic one woman at a time.

Personal Data. Present Symptoms

You re NOT Losing Your Mind You ARE Losing Your Hormones!

Emotional Relationships Social Life Sexually Recreation

DO YOU HAVE ADRENAL FATIGUE?

ALCOHOL & PERIMENOPAUSE

Angelica archangelica

Waccamaw Chiropractic & Wellness Center

Chapter 5. The Ovary Type Taken from Dr. Berg s book, The 7 Principles of Fat Burning. The Ovaries

Welcome! The Glandular System. Rachel Rauch. How the adrenal glands affect the thyroid, pancreas, pituitary, hypothalamus and sex hormones.

Welcome! Type in Your Questions! 7/9/2013. A recording of this webinar will be available at

Labrix Clinical Services, Inc.

Directions to Whole Woman Health - located in the NW Des Moines/Beaverdale area:

METABOLIC ASSESSMENT FORM

Silent Inflammation Questionnaire

Female Hormone Questionnaire

Test Results SB Samples Arrived: 06/26/2013 Samples Collected: Saliva: 06/21/13 06:45 Date Closed: 06/29/2013

HORMONE BALANCE QUESTIONNAIRE FOR WOMEN

Test Results SB Samples Arrived: 04/06/2016 Samples Collected: Saliva: 04/04/16 06:45. Saliva: 04/04/16 11:30

Pitta 5 1 = 9. My hair is fine with a tendency towards early thinning or graying. My joints are loose and flexible.

Dr. Ann Haiden,DO. What Health Challenge Type are You? Take the Quizzes. You can tell that something is not right. But what?

ABA Chiropractic Holistic Health Center Nutritional Assessment

Menopause 101. Sharzad Green, Pharm.D. Community Clinical Pharmacy

MEDICAL QUESTIONNAIRE (female)

New Client Health & Wellness Paper Work

DR. HEDAYA S PSYCHO-METABOLIC QUESTIONNAIRE

MICRO SAMPLE ASSAYS Result Range Units

Women s Fertility Symptom Survey

Other Courses to Consider

New Patient Specialty Intake Form Department of Surgery

DRIED URINE TESTING-INTEGRATIVE MEDICINE

Female New Patient Questionnaire

MD LONGEVITY CLIENT CONTACT INFORMATION. First Name: MI: Last Name. Billing Address: Street: City: State: Zip Code: Street: City: State: Zip Code:

WHI Form 55 Estrogen-Alone Survey Ver. 2

Medical History Form

Messer Chiropractic Amanda L. Messer, D.C E. Interstate Ave #21

Denise E. Bruner, M.D. & Associates, P.C.

BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:


The Physical and Emotional Toll of Hormone Imbalance for Women. Sally Brooks

DR. HEDAYA S PSYCHO-METABOLIC QUESTIONNAIRE The National Centers for Whole Psychiatry wholepsych.com phone:

Flashpoint: Regulating Your Body s Temperature. Presented by: Shari M. Lawson, MD MBA Date Presented: November 1,

Medical History Form

Objectives. Disclaimer 2/16/2015

Transcription:

Estrogen Self Test Check yes if you experience the associated low estrogen symptom. Are you experiencing hot flashes? Do you feel exhausted on a daily basis? Do you suffer from headaches/migraines? Do you suffer from night sweats? Are you experiencing vaginal dryness? Have you noticed mild losses of bladder control? Are you noticing bouts of mild to severe depression? Have you had a history of urinary tract infections? Has there been an increase in forgetfulness Are you having trouble concentrating? Have you noticed a decrease in your ability to explain things? Are you noticing increased upper lip wrinkles? Are you more moody? Do you cry easily? A score of 0-4 Most likely no need of estrogen bio-identical hormone replacement therapy A score of 5-8 Most likely in need of low dose estrogen bio-identical hormone replacement therapy A score of 8+ No doubt there is a need of estrogen bio-identical hormone replacement therapy If you answered yes to more than 5 questions, we recommend testing your Progesterone to Estrogen Ratio. Progesterone should be 200 to 1 meaning you should have 200 molecules of progesterone to every molecule of

Progesterone Self Test Check yes if you experience the associated low progesterone symptom. Are you noticing lumpiness in your breasts? Are you experiencing anxiety? Do you have a problem with bloating? Do you become easily stressed? Are you less cuddly? Are you experiencing breakthrough bleeding? Do you suffer from menstrual cramps or PMS? Do you suffer from Low body temperature? Do you have or have a family history of endometriosis or PCOS? Do you suffer from sleep disturbances? Do you have heavy periods? Do you snore? Are you experiencing pain in multiple areas of your body? Have you had an increase in weight? A score of 0-4 Most likely no need of progesterone bio-identical hormone replacement therapy A score of 5-8 Most likely a need of progesterone bio-identical hormone replacement therapy A score of 8+ No doubt there is a need of progesterone bio-identical hormone replacement therapy If you answered yes to more than 5 questions, we recommend testing your Progesterone to Estrogen Ratio. Progesterone should be 200 to 1 meaning you should have 200 molecules of progesterone to every molecule of

Testosterone Self Test Check yes if you experience the associated low testosterone symptom. Has your sex drive decreased? Have you noticed increased belly fat? Have you noticed an increase in the size of your breasts? Are you developing cellulite? Have you had a decrease in self esteem? Do you feel like flopping onto the couch after work? Are your eyelids drooping? Have you noticed that your hair is thinning? Do you feel irritable? Are you gaining weight? Are you losing muscle mass? Do you have high triglycerides or cholesterol? Have you noticed that climaxing is difficult? Do you have diminished Physical Performance? A score of 0-4 Most likely no need of testosterone bio-identical hormone replacement therapy A score of 5-8 Most likely need low doses of testosterone bio-identical hormone replacement therapy A score of 8+ No doubt there is a need of testosterone bio-identical hormone replacement therapy If you answered yes to more than 5 questions, we recommend testing your Progesterone to Testosterone Ratio. Progesterone should be 60 to 1 meaning you should have 60 molecules of progesterone to every molecule of

Thyroid Self Test Check yes if you experience the associated low thyroid symptom. Are you sensitive to cold? Do you suffer from cold hands and feet? When you wake, do you have a puffy face and swollen eyelids? Do you put weight on easily? Do you have dry skin? Do you have trouble getting up in the morning? Do you suffer from constipation? Do you wake with morning stiffness? Do you feel like you re walking through mud? Have you have fibromyalgia, pain throughout your muscles? Are you forgetful? Are you chronically fatigued? Are your muscles cramping? Do you feel weak? A score of 0-4 Most likely no need of thyroid hormone replacement therapy A score of 5-8 Most likely need low doses of thyroid hormone replacement therapy A score of 8+ No doubt there is a need of thyroid hormone replacement therapy If you answered yes to more than 5 questions, we recommend testing your TSH, T4 and T3 Hormones. If you answered yes to more than 8, you need to test for antibodies that may indicated that you have an autoimmune disease called Hashimoto s. This can be very detrimental to your Please Continue Reading-Below!

If you have found that you may be hormonally challenged, we can test your hormones efficiently and quickly in the convenience of your own home. Click Below and we will send you to a web page to sign up for a test kit to be sent to your home. Click Here