Symptom Checklist Template For Women

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Symptom Checklist for WOMEN
Use each of the following checklists to determine signs & symptoms of hormone imbalance and help you choose the appropriate profile.
Category 1: Basic Hormone Imbalance
Mark which of the following factors/symptoms are present and/or persist over time.
_____ Night sweats
_____ Hot flashes
_____ Mood swings (PMS)
_____ Urinary incontinence
_____ Heart palpitations
_____ Cystic ovaries
_____ Vaginal dryness
_____ Acne
_____ Heavy menses
_____ Foggy thinking
_____ Weight gain
_____ Depressed mood
_____ Fibrocystic breasts
_____ Irritability
_____ Increased body/facial
_____ Headaches
_____ Low libido/decreased
_____ Uterine fibroids
hair
_____ Bone loss
sexual function
Category 2: Adrenal Hormone Imbalance
Mark which of the following factors/symptoms are present and/or persist over time.
_____ Aches and pains
_____ Weight gain
_____ Food cravings
_____ Morning fatigue
_____ Susceptibility to infections
_____ Sleep disturbances
_____ Depression
_____ Anxiety
_____ Chronic health
_____ Evening fatigue
_____ Autoimmune diseases
_____ Allergies
_____ Diabetes/prediabetes
problems
_____ History of steroid usage
_____ Bone loss
_____ Low blood sugar
Category 3: Thyroid Hormone Imbalance
Mark which of the following factors/symptoms are present and/or persist over time.
_____ Aches and pains
_____ Anxiety
_____ Brittle nails
_____ Depression
_____ Dry skin
_____ Cold hands and feet
_____ Headaches
_____ Infertility
_____ Fatigue
_____ Foggy thinking
_____ Weight gain
_____ Feeling cold all the time
_____ Sleep disturbances
_____ Heart palpitations
_____ Low libido
_____ Inability to lose weight
_____ Constipation
_____ Thinning hair
_____ Menstrual irregularities
_____ Elevated cholesterol
Category 4: Cardiometabolic Risk
Mark which of the following factors/symptoms are present and/or persist over time.
_____ History of smoking
_____ Weight gain
_____ Heart disease or family history of heart disease
_____ High blood sugar
_____ Sugar cravings
_____ Diabetes or family history of diabetes
_____ High blood pressure
_____ Fatigue
_____ Waist size greater than 35 inches
_____ Low physical activity
_____ Elevated triglycerides
f you checked symptoms in all four categories, the suggested test
If you checked symptoms ONLY in Category 3, the suggested test
I
profiles are:
profiles are:
MINIMUM: Female Blood Profile II (Blood Spot)
MINIMUM: Essential Thyroid Profile (Blood Spot)
PREFERRED: Comprehensive Female Profile I or II (Saliva/Blood Spot)
PREFERRED: Comprehensive Female Profile I or II (Saliva/Blood
and CardioMetabolic Profile (Blood Spot)
Spot); OR Comprehensive Thyroid Profile (Blood Spot/Dried Urine)
plus Female/Male Saliva Profile III (Saliva)
If you checked symptoms ONLY in Category 1, the suggested test
profiles are:
If you checked symptoms ONLY in Category 4, the suggested test
MINIMUM: Female Blood Profile I (Blood Spot) or Female/Male Saliva
profiles are:
Profile I (Saliva)
MINIMUM: CardioMetabolic Profile (Blood Spot)
PREFERRED: Comprehensive Female Profile I or II (Saliva/Blood Spot)
PREFERRED: CardioMetabolic Profile (Blood Spot) plus Female/
Male Saliva Profile III (Saliva)
If you checked symptoms ONLY in Category 2, the suggested test
profiles are:
MINIMUM: Adrenal Stress Profile (Saliva)
PREFERRED: Comprehensive Female Profile I or II (Saliva/Blood Spot)
866.600.1636 | |
Revised 10.07.14

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