Hormone Imbalance Survey1. Decline in general well being Never Mild Moderate Severe2. Joint pain/muscle ache Never Mild Moderate Severe3. Excessive sweating/ hot flashes Never Mild Moderate Severe4. Sleep problems Never Mild Moderate Severe5. Irritability Never Mild Moderate Severe6. Nervousness Never Mild Moderate Severe7. Anxiety Never Mild Moderate Severe8. Depressed mood Never Mild Moderate Severe9. Exhaustion/lacking vitality Never Mild Moderate Severe10. Declining mental ability/focus/concentration Never Mild Moderate Severe11. Decreased muscle strength Never Mild Moderate Severe12. Weight gain/ increased belly fat / inability to lose weight Never Mild Moderate Severe13. Breast tenderness Never Mild Moderate Severe14. Rapid hair loss Never Mild Moderate Severe15. Migraine headaches Never Mild Moderate Severe16. Decreased sexual libido/desire Never Mild Moderate Severe17. Decreased ability to perform sexually/climax Never Mild Moderate Severe18. Dry skin Never Mild Moderate Severe19. Cold all the time Never Mild Moderate Severe20. Constipation Never Mild Moderate Severe21. White spots on nails Never Mild Moderate Severe22. Bruise easily Never Mild Moderate Severe23. Loud noises bother you Never Mild Moderate Severe24. Frequent heartburn Never Mild Moderate Severe25. Wake up tired Never Mild Moderate SevereTotal0-40: Fairly healthy; 40-60: Some hormonal imbalance is likely; 60 or more: Deficiency is probable.If your score is 40 or higher, please contact us immediately at 703-729-5553!Δ
