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  • Hormonal Imbalance Assessment-4

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    This document is a hormonal imbalance assessment that consists of 8 parts assessing different symptoms. It instructs the user to check off any symptoms they have experienced. A total score for each part indicates the likelihood of an imbalance: 1-2 symptoms is probably not contributing, 3-4 needs attention, and 5-6 likely indicates a major imbalance. The parts assess for high or low levels of cortisol, estrogen, progesterone, testosterone, and thyroid hormones. The user is provided a key to understand their scores and what they may indicate in terms of hormonal imbalances.

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    This document is a hormonal imbalance assessment that consists of 8 parts assessing different symptoms. It instructs the user to check off any symptoms they have experienced. A total score for each part indicates the likelihood of an imbalance: 1-2 symptoms is probably not contributing, 3-4 needs attention, and 5-6 likely indicates a major imbalance. The parts assess for high or low levels of cortisol, estrogen, progesterone, testosterone, and thyroid hormones. The user is provided a key to understand their scores and what they may indicate in terms of hormonal imbalances.

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    © All Rights Reserved
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    14 views10 pages

    Hormonal Imbalance Assessment-4

    Uploaded by

    kalyanichinnu07
    This document is a hormonal imbalance assessment that consists of 8 parts assessing different symptoms. It instructs the user to check off any symptoms they have experienced. A total score for each part indicates the likelihood of an imbalance: 1-2 symptoms is probably not contributing, 3-4 needs attention, and 5-6 likely indicates a major imbalance. The parts assess for high or low levels of cortisol, estrogen, progesterone, testosterone, and thyroid hormones. The user is provided a key to understand their scores and what they may indicate in terms of hormonal imbalances.

    Copyright:

    © All Rights Reserved
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    of 10

    HORMONAL IMBALANCE ASSESSMENT

    Think critically about each statement and if


    it applies to you. If you have the occasional
    bad day, don't mark down depression, if
    you experience bloating after eating most
    anything and it is extremely uncomfortable,
    check that box.
    HORMONAL IMBALANCE ASSESSMENT
    Part 1:
    I have experienced the following:

    Overwhelmed by the stress In my life

    Tired at night, but mind won't shut off (tired but wired)

    Difficulty falling or staying asleep

    Easily distracted, especially when stressed

    Increased irritability

    High blood pressure and/or high blood sugar

    Poor memory, especially under times of stress

    Prone to injury and it takes longer to recover

    Unintentional weight gain (especially around the middle)

    Total:
    HORMONAL IMBALANCE ASSESSMENT
    Part 2
    I have experienced the following:
    Tired after waking up, even if I've slept well

    Dependent on caffeine to get me through the day

    I need a nap most days

    I crave salty or sweet foods

    Difficulty falling asleep and/or staying asleep

    Muscle weakness

    Become dizzy if I stand up too quickly

    Get sick often and have a diffuclt time recovering

    Total:
    HORMONAL IMBALANCE ASSESSMENT
    Part 3

    I have experienced the following:

    Bloating

    Irritability/mood swings

    Heavy, painful periods

    Gained weight and have difficulty losing it

    Crying over nothing

    Frequent Migrains or headaches

    Brain Fog

    Total:
    HORMONAL IMBALANCE ASSESSMENT
    Part 4
    I have experienced the following:
    Poor Memory

    Emotioinal fragiliity

    Night sweats or hot flashes

    Bladder infections

    Sagging in breasts

    Achy joinits

    Loss of interest in exercise

    Vaginal dryness

    Lack of lubrication (dry skin, eyes, vagina etc.)

    Noticing more fine lines/wrinkles

    Low Libido

    Periods are fewer than 3 days

    Total:
    HORMONAL IMBALANCE ASSESSMENT

    Part 5
    I have experienced the following:

    PMS symptoms the week before my period

    Headaches/migraines around my period

    Anxiety

    Painful, heavy, or generally difficult periods

    Painful or swollen breasts prior to my period

    Miscarriage in the first trimester

    Irritable or emotional before my period

    Restless leg syndrome, especially at night

    Difficulty getting pregnant

    Total:
    HORMONAL IMBALANCE ASSESSMENT
    Part 6
    I have experienced the following:

    Acne

    Dark patches of skin (armpits)

    Thinning of my hair

    Skin tags

    Abnormal hair growth on face, chest, and/or abdomen

    Depression and/or anxiety

    Suspected or confirmed PCOS

    Dfficulty getting pregnant

    Total:
    HORMONAL IMBALANCE ASSESSMENT
    Part 7
    I have experienced the following:

    Low libido

    Depression, mood swings, and/or cry easily

    Decreased or a lack of motivation

    Losing muscle mass and can't seem to gain muscle

    Difficult time having orgasms

    Weight gain

    Fatigued throughout the day

    Decrease in bone density

    Total:
    HORMONAL IMBALANCE ASSESSMENT
    Part 8
    I have experienced the following:
    Hair Loss

    Dry Skin

    Thin, brittle fingernails

    Fluid retention

    Unintentional weight gain

    Recurring headaches

    Cold hands/feet or a sensitive to the cold

    Lethargy and/or fatigue

    Difficulty concentrating

    Low Libido

    Depression or moodiness

    My periodscome more than 35 days apart

    High Cholesterol

    Total:
    KEY
    1-2: Probably not a contributing imbalance

    3-4: Needs attention

    5-6: Likely a major hormonal imbalance that


    needs to be addressed

    Part 1: High Cortisol


    Part 2: Low Cortisol
    Part 3: High Estrogen
    Part 4: Low Estrogen
    Part 5: Low Progesterone
    Part 6: High Testosterone
    Part 7: Low Testosterone
    Part 8: Low Thyroid Hormones

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