Hormone Imbalance Survey 1. Decline in general well being Never Mild Moderate Severe 2. Joint pain/muscle ache Never Mild Moderate Severe 3. Excessive sweating/ hot flashes Never Mild Moderate Severe 4. Sleep problems Never Mild Moderate Severe 5. Irritability Never Mild Moderate Severe 6. Nervousness Never Mild Moderate Severe 7. Anxiety Never Mild Moderate Severe 8. Depressed mood Never Mild Moderate Severe 9. Exhaustion/lacking vitality Never Mild Moderate Severe 10. Declining mental ability/focus/concentration Never Mild Moderate Severe 11. Decreased muscle strength Never Mild Moderate Severe 12. Weight gain/ increased belly fat / inability to lose weight Never Mild Moderate Severe 13. Breast tenderness Never Mild Moderate Severe 14. Rapid hair loss Never Mild Moderate Severe 15. Migraine headaches Never Mild Moderate Severe 16. Decreased sexual libido/desire Never Mild Moderate Severe 17. Decreased ability to perform sexually/climax Never Mild Moderate Severe 18. Dry skin Never Mild Moderate Severe 19. Cold all the time Never Mild Moderate Severe 20. Constipation Never Mild Moderate Severe 21. White spots on nails Never Mild Moderate Severe 22. Bruise easily Never Mild Moderate Severe 23. Loud noises bother you Never Mild Moderate Severe 24. Frequent heartburn Never Mild Moderate Severe 25. Wake up tired Never Mild Moderate Severe Total0-40: 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
