hormone analysis
advertisement
YOUR OFFICE INFO HERE Name:_________________________________________________ Date:_____________________ Answer the following questions as honestly as possible. Think about how you have been feeling over the previous month and how often you have been bothered by any of the following problems. Score the occurrence of each symptom on the following scale: none, mild, moderate, severe. Section 1: Symptom Frequency Score 0 None 1 Mild 2 Moderate _____ 1. Unexplained fevers, sweats, chills, or flushing 3 Severe _____ 20. Muscle pain or cramps _____ 21. Twitching of the face or other muscles _____ 2. Unexplained weight change: loss or gain _____ 22. Headaches _____ 3. Fatigue, tiredness _____ 23. Neck cracks or neck stiffness _____ 4. Unexplained hair loss _____ 24. Tingling, numbness, burning, or stabbing _____ 5. Swollen glands sensations _____ 6. Sore throat _____ 25. Facial paralysis (Bell’s palsy) _____ 7. Testicular or pelvic pain _____ 26. Eyes/vision: double, blurry _____ 8. Unexplained menstrual irregularity _____ 27. Ears/ hearing: buzzing, ringing, ear pain _____ 9. Unexplained breast milk production; _____ 28. Increased motion sickness, vertigo breast pain _____ 10. Irritable bladder or bladder dysfunction _____ 29. Light-headedness, poor balance, difficulty walking _____ 11. Sexual dysfunction or loss of libido _____ 30. Tremors _____ 12. Upset stomach _____ 31. Confusion, difficulty thinking _____ 13. Altered bowel function (constipation or _____ 32. Difficulty with concentration or reading diarrhea) _____ 14. Chest pain or rib soreness _____ 15. Shortness of breath or cough _____ 16. Heart palpitations, pulse skips, heart blocks _____ 17. History of a heart murmur or valve prolapse _____ 18. Joint pain or swelling _____ 19. Stiffness of the neck or back _____ 33. Forgetfulness, poor short term memory _____ 34. Disorientation: getting lost; going to wrong places _____ 35. Difficulty with speech or writing _____ 36. Mood swings, irritably, depression _____ 37. Disturbed sleep: too much, too little, early awakening _____ 38. Exaggerated symptoms or worse hangover from alcohol Add up your totals from each of the four columns. This is your first score. Score: ______ YOUR OFFICE INFO HERE Section 2: Common Symptom Emphasis If you rated a 3 for all of the above in section 1, give yourself 5 additional points: _____Fatigue (#3) _____Forgetfulness, poor short term memory (#33) _____Joint pain or swelling (#18) _____Tingling, numbness, burning, or stabbing sensations (#24) _____Disturbed sleep: too much, too little, early awakening (#37) Score: ______ Section 3: Lyme Incidence Score Now please circle the points for each of the following statements you can agree with: 1. You have had a tick bite with no rash or flu-like symptoms. 3 points 2. You have had a tick bite, an erythema migrans (a bullseye rash), or an unidentified rash, followed by flu-like symptoms. 5 points 3. You live in what is considered a Lyme-endemic area. 2 points 4. You have a family member or roommate (same household) who has been diagnosed with Lyme and/or other tick borne infections. 1 point 5. You experience migratory muscle pain (moves around). 4 points 6. You experience migratory joint pain (moves around). 4 points 7. You experience tingling/ burning/ numbness that migrates and/or comes and goes. 4 points 8. You have received a prior diagnosis of chronic fatigue syndrome or fibromyalgia. 3 points 9. You have received a prior diagnosis of a specific autoimmune disorder (lupus, MS, or rheumatoid arthritis), or of a nonspecific autoimmune disorder. 3 points 10. You have had a positive Lyme test (IFA, ELISA, Western blot, PCR, and/or borrelia culture). 5 points Score: ______ Section 4: Overall Health Score 1. Thinking about your overall physical health, for how many of the past thirty days was your physical health not good? ______days Award yourself the following points based on the total number of days: 0-5 days = 1 point 6-12 days = 2 points 13-20 days = 3 points 21-30 days = 4 points Score:______ YOUR OFFICE INFO HERE 2. Thinking about your overall mental health, for how many days during the past thirty days was your mental health not good? ______days 0-5 days = 1 point 6-12 days = 2 points 13-20 days = 3 points 21-30 days = 4 points Score: ______ Calculating Your Score for Part A: Record your total scores for each section above and add them together to achieve your final score: Section 1 total: ______ Section 2 total: ______ Section 3 total: ______ Section 4 total: ______ Final Score: ______ If you scored 46 or more, you have a high probability of a tick-borne disorder and should see a healthcare provider for further evaluation and/or seek the support of a holistic wellness professional. If you scored between 21-45, you possibly have a tick-borne disorder and should see a health-care provider for further evaluation and/or seek the support of a holistic wellness professional. If you scored under 21, you are not likely to have a tick-borne disorder. HORMONE ANALYSIS Section 5: Estrogen Deficiency Signs, Symptoms and Associations of Estrogen Deficiency (Check any symptoms you have) ______Hot flashes ______Night sweats ______Vaginal dryness ______Mental fuzziness ______Vaginal and /or bladder infections ______Vaginal wall thinning ______ Decreased sexual response ______ Vision changes ______Trouble expressing thought ______Memory loss ______Low HDL ______ Mood swings (mostly irritability and depression) ______Incontinence; or recurrent urinary tract infection ______Decreased menstrual bleeding ______Decreased fullness in breast ______Wrinkling of skin ______Losing track of thoughts _____ Total checkmarks in Section 5 Section 6: Low Adrenals Signs, Symptoms and Associations of Low Adrenals YOUR OFFICE INFO HERE (Check any symptoms you have) ______Infertility ______Joint pain ______Frequent infections ______Shakiness relieved by eating ______Dizziness ______Moodiness ______Low blood pressure ______Dizziness upon first standing ______Food craving or sensitivities ______Postpartum depression ______Depression ______PMS ______Poor perspiration ______Poor concentration ______Chronic fatigue ______Fibromyalgia ______Cravings for sweets ______Irritability ______Hypoglycemia (low blood sugar episodes) ______Allergies or asthma that started as an adult ______Recurrent infections that take a long time to resolve ______A lot of stress in your life before your symptoms began _____ Total checkmarks in Section 6 Section 7: Growth Hormone Deficiency Signs, Symptoms and Associations of Growth Hormone Deficiency (Check any symptoms you have) _____Permanent fatigue _____Easy exhaustion _____Poor resistance to stress _____Depression _____Low self esteem _____Sense of powerlessness _____Poor sociability _____Anxiety _____Complacency _____Emotional instability _____Grumpy _____Sagging cheeks _____Wrinkled face _____Pouches under the eyes _____Loose skin folds under the chin _____Drooping triceps _____ Total checkmarks in Section 7 _____Floppy belly _____Poor muscle tone _____Wrinkled hands _____Fatty cushions above the knees _____Thinned skin or sagging skin _____Obesity _____Thin hair _____Thin lips _____Receding gum line _____Trouble losing weight _____Age over 40 _____Can‘t gain muscle with exercise _____Feel old _____Low resistance when staying up after midnight YOUR OFFICE INFO HERE Section 8: Progesterone Deficiency Signs, Symptoms and Associations of Progesterone Deficiency (Check any symptoms you have) _____Abdominal bloating or swelling _____Acne _____Angry outbursts _____Anxiety _____Appetite changes, decreased/ increased _____Asthmatic attacks _____Avoidance of social activities _____Backache _____Bladder irritation _____Bleeding gums _____Breast swelling/ tenderness _____Bruising _____Clumsiness _____Confusion _____Conjunctivitis _____Constipation _____Cramps _____Craving salty foods _____Craving sweet foods _____Crying spells _____Decreased hearing _____Decreased productivity at school or work _____Decreased sex drive _____Depression _____Distractibility _____Dizziness _____Drowsiness _____Dull abdominal pain _____Eye pain _____Facial swelling _____Fatigue _____Fear of going out alone (agoraphobia) _____Fear of losing control _____Finger swelling _____Food sensitivity _____Forgetfulness _____Generalized aches and pains _____Headaches _____ Total checkmarks in Section 8 _____Herpes (cold sores) _____Hives or rashes _____Hot flashes _____Increased alcohol consumption _____Increased sensitivity to light _____Increased sensitivity to noise _____Inefficiency _____Indecision _____Insomnia _____Irritability _____Joint pains _____Leg cramps _____Leg swelling _____Mood swings _____Mouth sores _____Muscle aches or tenderness _____Nausea _____Palpitations _____Panic attacks _____Poor coordination _____Poor judgment _____Poor memory _____Postpartum depression _____Restlessness _____Ringing in ears _____Runny nose _____Seizures _____Sinusitis _____Sore throat _____Spots in front of eyes _____Suspiciousness _____Tearfulness _____Tension _____Tingling in hands and feet _____Tremors _____Visual changes _____Vomiting YOUR OFFICE INFO HERE Section 9: Yeast Overgrowth Signs, Symptoms and Associations of Yeast Overgrowth History: Check all items that apply to you ______Have you ever taken tetracyclines or other antibiotics for acne for 1 month or longer? ______ Have you at any time in your life taken broad-spectrum antibiotics or other antibacterial medication for respiratory, urinary or other infections for 2 months or longer, or in shorter courses, 4 or more times in a 1-year period? ______ Have you ever taken a broad spectrum antibiotic drug- even in a single dose? ______ Have you at any time in your life been bothered by persistent prostatitis, vaginitis or other problems affecting your reproductive organs? ______ Are you bothered by memory or concentration problems- do you sometimes feel spaced out? ______ Do you feel “sick all over” yet, despite visits to many different physicians, the causes haven’t been found? ______ Have you ever been pregnant? ______ Have you ever taken birth control pills? ______ Have you ever taken steroids orally, by injection or inhalation? ______ Does overexposure to perfumes, insecticides, fabric shop odors and other chemicals provoke symptoms? ______ Does tobacco smoke really bother you? ______ Are your symptoms worse on damp, muggy days or in moldy places? ______ Have you ever had athlete’s foot, ring worm, “jock itch” or other chronic fungus infections of the skin or nails? ______ Do you crave sugar? Check the following symptoms you have: ______Fatigue or lethargy ______ Feeling of being “drained” ______ Depression or manic depression ______ Numbness, burning or tingling ______ Muscle aches ______ Muscle weakness or paralysis ______ Pain and/or swelling in joints ______ Headache ______Abdominal pain ______ Constipation and/or diarrhea ______ Bloating, belching or intestinal gas ______ Prostatitis ______ Impotence ______ Loss of sexual desire or feeling ______ Endometriosis or infertility ______ premenstrual tension ______ Attacks of anxiety or crying ______ Hypothyroidism ______ Shaking or irritable when hungry ______ Cystitis or interstitial cystitis ______ Irritability ______ Frequent mood swings ______ Dizziness/ loss of balance ______ Eczema ______ Psoriasis ______Indigestion or heartburn ______ Mucus in stools ______ Dry mouth or throat ______ Tendency to bruise easily ______ Itching eyes ______ Chronic hives (urticaria) ______ Sore throat ______Cough or recurrent bronchitis ______ Wheezing or shortness of breath ______ Burning on urination ______ Burning or tearing eyes ______ Bad breath ______ Nasal congestion or postnasal drip ______ Laryngitis, loss of voice ______ Pain or tightness in chest YOUR OFFICE INFO HERE ______ Urinary frequency or urgency ______ Spots in front of eyes or erratic vision ______ Recurrent infections or fluid in ears ______ Ear pain or deafness ______ Incoordination ______ Insomnia ______ Rectal itching ______ Cold hands or feet, low body temperature ______ Mouth rashes, including “white” tongue ______ Troublesome vaginal burning, itching or discharge ______ Sinus problems…tenderness of cheekbones or forehead ______ Cramps and/or other menstrual irregularities ______ Drowsiness, including inappropriate drowsiness ______ Pressure above ears…. Feeling of head swelling ______ Sensitivity to milk, wheat, corn or other common foods ______ Foot, hair or body odor not relieved by washing Section 10: Testosterone Deficiency Signs, Symptoms and Associations of Testosterone Deficiency (Check any symptoms you have) _____Overall decreased sexual desire _____Diminished vital energy and sense of well being _____Decreased sensitivity to sexual stimulation in the clitoris _____Decreased sensitivity to sexual stimulation in the nipples _____Overall decreased arousability and capacity for orgasm _____Thinning and loss of pubic hair _____Osteoporosis _____Depression _____Decreased morning erections _____Decrease in stiffness of erections _____Difficulty maintaining erections _____Mental fatigue _____Complacency _____Loss of initiative _____Decreased interest in hobbies _____Crying spells _____Poor muscle tone _____Inability to grow muscle _____Poor stamina _____High cholesterol _____Increased breast tissue in males _____Night sweats _____Poor memory _____Decreased sexual thoughts Section 11: Signs, Symptoms and Associations of Stomach Acid Issues _____Burping after meals _____Feeling unwell/ fatigued right after meals _____Food or water “sits in stomach” _____Undigested food in stool _____Reflux &/or heartburn _____Poor appetite or feel overly full easily _____Multiple food sensitivities/food allergies _____Trouble digesting red meat _____Constipation _____Low iron levels _____Frequent nausea _____Prescribed antacids or acid-blockers _____High fat foods cause nausea/ stomach upset _____Stomach aching/pain/ discomfort or bloating after meals _____Nausea/ reflux after supplements (e.g. fish oil YOUR OFFICE INFO HERE Section 12: Hypothyroidism Signs and Symptoms Related to Hypothyroidism ______ Dry hair or hair loss ______ Constipation ______ Heavy menstrual periods ______ Milky discharge from breasts ______ Joint aches and pains ______ Sweating less ______ Brittle nails ______ Hoarse voice ______ Muscle cramps ______ Tingling or numbness in fingers or feet ______ Dry skin ______ Hearing becomes worse ______ Puffy eyes and face ______ Slow heartbeat ______ Cold intolerance ______ Experiencing stiffness ______ Weight gain of more than 5 lbs. ______ Feeling more fatigued ______ Skin becoming more coarse ______ Dry eyes/ mouth ______ Baggy eyelids ______ Slow speech and movement ______ Sleep apnea ______ Low blood pressure ______ Decrease in memory ______ Problems swallowing ______ Carpal tunnel syndrome ______ Headaches and migraines ______ Uterine fibroids ______ Yellow skin in palms ______ Scalloped tongue ______ Increased cholesterol/ triglycerides/ LDL ______ Cold hands/ feet ______ Yeast infections ______ Loss of outside 1/3 of eyebrows ______ Depression/ anxiety ______ Swelling of hands and feet ______ Infertility ______ Slow thinking ______ Miscarriages ______ Reliance on coffee or other stimulants ______ Lumps in breasts ______ Gum problems ______ Low sex drive ______ Anemia ______ Redness in face with exercise ______ Tongue biting ______ Tendonitis/ tennis elbow ______ Low endurance ______ Thick tongue ______ No energy for evening activities ______ Throat clearing ______ Cracking in skin of heels ______ Diabetes ______ Alopecia (patches of hair loss) ______ Premature graying of hair ______ Stroke ______ Blocked arteries ______ Polymyalgia ______ Vitiligo (loss of skin pigmentation) ______ High blood pressure ______ Low HDL ______ Manic depression ______ Dyslexia ______ Attention deficit disorder ______ Melasma (discoloration in face) ______ Excess ear wax ______ Neck injury i.e. whiplash ______ Ligament tears ______ Family history of hypothyroidism or ______ hyperthyroidism ______ Chronic infections ______ Skin problems (hives, psoriasis, eczema) ______ Postpartum depression ______ Raynaud’s syndrome (Pain and bluing of fingers with exposure to cold) ______ Inability to lose weight with diet and exercise ______ Oral temperature consistently below 98.5 ______ Exaggerated PMS/ menopause symptoms ______ Autoimmune disease (Rheumatoid Arthritis, Lupus, Chrohn’s ect.) ______ Shortness of breath during mild exertion YOUR OFFICE INFO HERE Section 13: Estrogen Dominance Signs, Symptoms and Associations of Estrogen Dominance (Check any symptoms you have) _____Insulin resistance or Type II diabetes _____Attention Deficit Disorder _____Anxiety, often with depression _____Breast cancer _____Breast tenderness _____Calcium deposits _____Cervical dysplasia (class 3 pap smear) _____Cold hands and feet _____Craving of sweets _____Decreased sex drive _____Depression with anxiety or agitation _____Dry eyes _____Early onset of menstruation _____Endometrial (uterine) cancer _____Fatigue _____Fibrocystic breasts _____Fluid retention _____Gall bladder disease _____Good skin _____Headaches _____Heavy menses _____Hypoglycemia _____Inability to lose weight _____Increased HDL _____Infertility _____Irritability _____Insomnia _____Large breast _____Loss of scalp hair _____Migraines _____Mood swings _____Palpitations _____Panic attacks _____Excessive vaginal bleeding _____Water retention, bloating _____Prostate cancer/ enlarged prostate _____Sluggish metabolism _____PMS _____Weight gain _____Yeast infections _____Increased sensitivity to sight, sound, or emotion _____Increased blood clotting (increasing risk of stroke) _____Fat gain, especially around the hips, thighs, and back of arms _____Allergies, including asthma, hives, rashes, sinus congestion _____Symptoms of hypothyroidism with normal thyroid blood test _____Autoimmune disorders such as lupus, erythematosus and Hashimoto’s thyroiditis and possibly Sjorgren’s syndrome (dry mouth/eyes) Disclaimer & Contact Info Here
