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Symptoms List Form

Symptoms List
All information on this form will be kept strictly confidential


Estrogen
Deficiency		 Estrogen Excess Progesterone
Deficiency		 Progesterone Excess
Hot Flashes Mood Swings (PMS) Hot Flashes Sleepiness
Night Sweats Tender Breasts Night Sweats Breast Tenderness
Vaginal Dryness Water Retention Vaginal Dryness Decreased Libido
Low Libido Nervous / Anxious Low Libido Mild Depression
Memory Lapses Irritable Memory Lapses Yeast Infection
Incontinence Fibrocystic Breasts Incontinence Bloating
Tearful / Depression Uterine Fibroids Tearful / Depression Water Retention
Sleep Disturbances Weight Gain In Hips Sleep Disturbances  
Heart Palpitations Headaches Heart Palpitations  
Bone Loss Endometrial Bleeding Bone Loss  
Aches / Pains Breast Cancer Aches / Pains  
Anxiety Uterine Cancer Anxiety  
Thinning Skin   Water Retention  
Hair Loss   Yeast Infection  
    Hair Loss  

Androgen Deficiency
 Androgen Excess
 Cortisol Deficiency
 Cortisol Excess
Low Libido Excessive Facial Hair Fatigue Sleep Disturbances
Vaginal Dryness Loss of Scalp Hair Sugar Craving Bone Loss
Foggy Thinking Increased Acne Allergies Fatigue
Hot Flashes Oily Skin Asthma Weight Gain - Waist
Night Sweats Tender Breasts Sinusitis Loss of Muscle Mass
Aches / Pains Anxiety Chemical Sensitivity Thinning Skin
Memory Lapses Ovarian Cysts Stress Anxiety
Incontinence   Aches / Pains Stress
Depressed   Arthritis Sugar Craving
Sleep Disturbances   Neck / Back Pain Memory Lapse
Decreased Muscle   Muscle Stiffness Hot Flashes
Bone Loss   Hives / Itching  
Thinning Skin   Fibromyalgia  
Fibromyalgia   Low Blood Pressure  
       

 
Thyroid Deficiency Thyroid Excess
Basal Body Temp <97 Weight Loss / Gain
Fatigue Fatigue
Lack of Endurance Shakiness
Dizziness Heat Intolerant
Joint Stiffness Restlessness
Depression Increased Thirst
Anxiety Hair Loss
Decreased Concentration Anemia
Muscle Weakness Increased Sweating
Headaches Hives / Itching
PMS Brittle Nails
Mood Swings Rapid Heartbeat
Irritability Chest Pain
Word Mix-Ups Shortness of Breath
Joint Pain / Aches Weakness
Swollen Fingers Decreased Muscle Mass
Brain Fog Irregular Menstrual Cycle
Memory Blanks Anxiety / Panic Attacks
  Depression / Irritability
  Emotional Swings/Aggression



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