EmailMe Form - ************FEMALE HORMONE SURVEY***********

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CRESTVIEW/FT WALTON/COLO SPRINGS
The following symptoms are usually the first to arise in Menopause or "Peri-Menopause". In fact it is not uncommon to have a fairly high score in the fist section and a low score under the "Estrogen" section. This would typically indicate the onset of Menopause.
A score between 0-9 is considered mild for either Menopause or Peri-Menopause. 10-15 moderate and over 15 Severe Progesterone-related Menopausal symptoms.
SYMPTOMS RELATED TO PROGESTERONE

NONE MILD MODERATE SEVERE EXTREME

MOOD SWINGS

INSOMNIA

WEIGHT GAIN

CHANGES IN MENSTRUAL CYCLE

BLOATING

PMS
A Subtotal of 0-7 is indicative of mild Estrogenic SX 8-12 moderate and over 12 severe. If you are already on therapy, and your score has decreased more than 4 points, you are on your way better hormonal health.
ESTROGEN DEFICIENT SYMPTOMS

NONE MILD MODERATE SEVERE EXTREME

HOT FLASHES

NIGHT SWEATS

VAGINAL DRYNESS

FREQUENT URINARY INFECTIONS
The symptom list below can occur with Menopause or at any other time. While they are not necessarily indicative of Menopause, they do lean towards Testosterone deficiency signs and symptoms.
Women usually notice an improvement in Libido and other sex-related symptoms after the first three months of therapy. Just elevating Testosterone isn't usually enough as "Balance" in other areas is usually necessary for overall improvement.
SYMTOMS RELATED TO LOW TESTOSTERONE

NONE MILD MODERATE SEVERE EXTREME

LACK OF SEXUAL DESIRE

INABILITY TO ACHIEVE ORGASM

POOR EXERCISE RECOVERY

LOSS OF MUSCLE TONE
An overall survey score of 0-17 would indicate mild Menopausal or Peri-Menopausal symptoms. A score between 18-28=Moderate and over 28=Severe to Extreme.
DO YOU STILL HAVE YOUR CYCLE ?
YES
NO
WHAT WAS THE DATE OF YOUR LAST CYCLE ?
MM / DD / YYYY
HAVE YOU HAD A TUBAL LIGATION
YES
NO
MAY WE CONTACT YOU REGARDING YOUR RESULTS ?
YES
NO
PLEASE SELECT PREFERRED CONTACT METHOD
NAME
First Last
EMAIL
LIST THE NAME AND STRENGTH OF ANY MEDICATIONS YOU ARE CURRENTLY TAKING.
BE SURE TO INCLUDE NAME STRENGTH AND FREQUENCY

	NONE	MILD	MODERATE	SEVERE	EXTREME
MOOD SWINGS
INSOMNIA
WEIGHT GAIN
CHANGES IN MENSTRUAL CYCLE
BLOATING
PMS

	NONE	MILD	MODERATE	SEVERE	EXTREME
HOT FLASHES
NIGHT SWEATS
VAGINAL DRYNESS
FREQUENT URINARY INFECTIONS

	NONE	MILD	MODERATE	SEVERE	EXTREME
LACK OF SEXUAL DESIRE
INABILITY TO ACHIEVE ORGASM
POOR EXERCISE RECOVERY
LOSS OF MUSCLE TONE

The following symptoms are usually the first to arise in Menopause or "Peri-Menopause". In fact it is not uncommon to have a fairly high score in the fist section and a low score under the "Estrogen" section. This would typically indicate the onset of Menopause.

The symptom list below can occur with Menopause or at any other time. While they are not necessarily indicative of Menopause, they do lean towards Testosterone deficiency signs and symptoms.

An overall survey score of 0-17 would indicate mild Menopausal or Peri-Menopausal symptoms. A score between 18-28=Moderate and over 28=Severe to Extreme.