I got this from ZRT Lab which is the company I use to test saliva hormones. You can purchase a kit and test hormones (about $35 per hormone)…email or call my office if you want one (I will post on the drgreenbean store as well)
Women
For Women
Category 1:
Basic Hormone ImbalanceNote which of the following symptoms are troublesome and/or persist over time.
_____ Hot fl ashes
_____ Heart palpitations
_____ Heavy menses
_____ Fibrocystic breasts
_____ Thinning skin
_____ Urinary incontinence
_____ Vaginal dryness
_____ Weight gain
_____ Increased body/facial
hair
Category 2:
Adrenal Hormone ImbalanceNote which of the following symptoms are troublesome and/or persist over time.
_____ Aches and pains
_____ Sleep disturbances
_____ Infertility
_____ Chronic illness
_____ Morning fatigue
_____ Anxiety
_____ Allergic conditions
_____ Susceptibility to infections
_____ Mood swings (PMS)
_____ Cystic ovaries
_____ Foggy thinking
_____ Irritability
_____ Uterine fi broids
_____ Night sweats
_____ Acne
_____ Depressed mood
_____ Headaches
_____ Bone loss
_____ Elevated triglycerides
_____ Depression
_____ Nervousness
_____ Evening fatigue
_____ Bone loss
_____ Blood sugar imbalance
_____ Autoimmune illness
ZRT Laboratory
• Phone: 503-466-2445 • Fax: 503-466-1636 • www.zrtlab.comCopyright © 2006 ZRT Laboratory, LLC. All rights reserved.
The following checklists can be used to help you and your healthcare provider
determine specifi c symptoms of hormone imbalance.
Category 3:
Thyroid Hormone ImbalanceNote which of the following symptoms are troublesome and/or persist over time.
_____ Aches and pains
_____ Dry skin
_____ Fatigue
_____ Heart palpitations
_____ Constipation
_____ Anxiety
_____ Cold hands and feet
_____ Foggy thinking
_____ Low libido
_____ Thinning hair
_____ Brittle nails
_____ Headaches
_____ Weight gain
_____ Inability to lose weight
_____ Menstrual irregularities
_____ Depression
_____ Infertility
_____ Feeling cold all the time
_____ Sleep disturbances
_____ Elevated cholesterol
Number selected _____
Number selected _____
Number selected _____
P
ATIENT CHECKLIST FOR SYMPTOMS OF HORMONE IMBALANCERev. 11.29.06
Men
P
ATIENT CHECKLIST FOR SYMPTOMS OF HORMONE IMBALANCEFor Men
Category 1:
Basic Hormone ImbalanceMark which of the following symptoms are troublesome and/or persist over time.
_____ Burned out feeling
_____ Hot fl ashes
_____ Weight gain waist
_____ Decreased libido
_____ Night sweats
_____ Insomnia
_____ Increased urinary urge
_____ Infertility problems
_____ Oily skin
_____ Apathy
Category 2:
Adrenal Hormone ImbalanceMark which of the following symptoms are troublesome and/or persist over time.
_____ Aches and pains
_____ Sleep disturbances
_____ Infertility
_____ Chronic illness
_____ Stress
_____ Morning fatigue
_____ Anxiety
_____ Allergic conditions
_____ Weight gain waist
_____ Decreased erections
_____ Irritable
_____ Erectile dysfunction
_____ Prostate problems
_____ Decreased mental
sharpness
_____ Decreased urine fl ow
_____ Decreased stamina
_____ Sleep disturbances
_____ Decreased muscle
mass
_____ Elevated triglycerides
_____ Depression
_____ Lack of motivation
_____ Prostate problems
_____ Evening fatigue
_____ Bone loss
_____ Blood sugar imbalance
_____ Autoimmune illness
_____ Fibromyalgia
_____ Susceptibility to
infections
ZRT Laboratory
• Phone: 503-466-2445 • Fax: 503-466-1636 • www.zrtlab.comCopyright © 2006 ZRT Laboratory, LLC. All rights reserved.
The following checklists can be used to help you and your healthcare provider
determine specifi c symptoms of hormone imbalance.
Category 3:
Thyroid Hormone ImbalanceMark which of the following symptoms are troublesome and/or persist over time.
_____ Low libido
_____ Foggy thinking
_____ Constipation
_____ Elevated cholesterol
_____ Depression
_____ Infertility
_____ Fatigue
_____ Cold body temperature
_____ Headaches
_____ Lack of motivation
_____ Decreased erections
_____ Sleep disturbances
_____ Inability to lose weight
Number selected _____
Number selected _____
Number selected _____
Rev. 11.29.06