Hormone Balance Evaluation Form

First Name *

Family Name *

Email Address *

Phone *

Year of Birth *

Date of the Last Period *

SYMPTOMS EVALUTION TABLE

(Symptoms Intensity: 0, 1,2,3 (0: No Symptoms, 1: Mild, 2: Medium, 3: Strong)

PHYSICAL SYMPTOMS

Hot Flushes *

Night Sweats *

Slow Digestion *

Low Energy / Fatigue *

Hair Loss / Weak Nails *

Intestinal Problems *

Weight Gain *

Feeling Bloated *

Joints Pain *

Headache / Migraine *

Dry Skin / Itching Skin *

Sore / Swollen Breast *

Irregular Periods *OR Heavy Periods

Allergies *

Heart Palpitations *

Tingling Extremities *

Body Temperature Swings *Hot/Cold

Insomnia / Sleeping Disorder *

Fat in the Belly Area & Arms *

MENTAL / EMOTIONAL

Anxiety *

Mood Swings *

Stressed *

Loss of Confidence *

Bursts of Anger *

Feeling Sad *

Panic Attacks *

Feeling Overwhelmed *

Brain Fog / Bad Memory *

Crying/Weeping with No Reason *

GENITOURINARY SYMPTOMS

Vaginal Dryness *

Vaginal Discharge *

Loss of Libido *

Bladder Issues / Incontinence *

Painful Sex *

GENERAL HEALTH (Check the related box, if Yes)

ARE YOU TAKING ANY MEDICATIONS OR SUPPLEMENTS?

E.g. Hormone replacement therapy (HRT), Anti-depresant, vitamins, magnesium...

Please write the name of the products you take

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