Self Assessment of Hormone Imbalances This self-assessment is designed to help you determine if your symptoms could possibly be due to hormone imbalances. Full Name* Email* Phone Date of Birth Please check off the boxes that apply to you. Do you have or have you experienced any of these symptoms in the past 6 months…… Low Progesterone Agitation or PMS Insomnia, easily disrupted sleep Weight Gain Cyclical headaches (particularly menstrual or hormonal migraines) Painful and/or swollen breasts Irregular menstrual cycles Heavy or painful periods Increased clumsiness or poor coordination Early miscarriage Infertility Low Testosterone Lack of Interest in Sex Decreased sexual satisfaction Lack of confidence and competitive drive Decreased Motivation (feeling blah) Harder time making decisions Decreased muscle tone Loss of bone density Low Estrogen Hot flashes or night sweats Weight gain Poor memory (you draw a blank midsentence) Wrinkles (your favourite skin cream no longer works) Achy joints (you feel older than you think you should feel) Lack of moisture (dry eyes, dry skin, dry clitoris) Vaginal dryness, irritation or loss of feeling (difficulty with orgasms) Droopy breasts, or breasts lessening in volume Low libido Painful intercourse Low Thyroid Cold hands and feet, Cold or Heat intolerance Slow brain, slow thoughts, difficulty concentrating Low blood pressure or slow pulse Thin, brittle fingernails Fluid retention or swollen ankles Decreased sweating Antidepressant no longer seem to help? An enlarged thyroid/goitre, difficulty swallowing, enlarged tongue Slow speech, perhaps with hoarse or halting voice Lethargy (you feel like you are moving through molasses) Sluggish reflexes, diminished reaction time, even a bit of apathy Excess Estrogen Bloating, puffiness, or water retention Heavy bleeding or postmenopausal bleeding Rapid weight gain particularly in the hips and buttocks Mood swings, PMS, depression, or just irritability Weepiness, sometimes over the most ridiculous things Mini breakdowns or Anxiety Endometriosis, or painful periods Migraines or other headaches A red thrush on your face (or a diagnosis of rosacea) Brain fog Excess Testosterone Excess hair on your face, chest, or arms Acne Greasy skin and/or hair Discoloration of your armpits (darker and thicker than your normal skin) Skin tags, especially on your neck and upper torso Reactivity and/or irritability, or excessively aggressive or authoritarian episodes Midcycle pain Ovarian cysts or Polycystic ovary syndrome Hyperglycemia or hypoglycemia and/or unstable blood sugar Stress/Cortisol Imbalance Hard time waking in the morning A feeling that you are constantly racing from one task to the next Feeling ‘wired and tired’ A struggle calming down before bedtime, or a second wind that keeps you up late Difficulty falling asleep or disrupted sleep Fatigue or burnout (need caffeine to bolster your energy, or falling asleep while reading or watching a movie) Loss of stamina, particularly in the afternoon, from 2-5pm? Decreased problem solving ability A quickness to feel anger or rage-frequent screaming or yelling High blood pressure or rapid heartbeat A feeling of anxiety or nervousness? Can’t stop worrying about things beyond your control Eczema, thin skin? More difficulty coping with stress Feel tired after exercising IF you answered moderate to high to most symptoms you are most likely experiencing hormone imbalance. Thank you for your time in completing this self-assessment. Please feel free to submit your symptom self-assessment to our clinic by hitting the submit button below. Dr. Sidhu can review this with you during your initial consultation and help you discover the most suitable therapy for your needs to help you get back to feeling your best again. This self-assessment is designed for informational purposes only and does not substitute for a professional medical diagnosis. Please verify your request.* Submit Marketing by ActiveCampaign