Please have patient rate their current symptoms from 0 to 5
  Possible Reasons % Possible reasons
Subjective Symptoms  Rating Subjective Symptoms  Rating Subjective Symptoms  Rating   Increased Estrogen
Acne Depressed Mood Low Blood Pressure   Decreased Estrogen
Anxiety / Nervousness Dry Eyes Memory Problems   Increased Progesterone
Apathy Dry Skin / Hair Mood Swings   Decreased Progesterone
Breast Tenderness Fatigue Muscle Pain   Increased Testosterone
Brittle Nails Fibrocystic Breasts Night Sweats   Decreased Testosterone
Burned Out Feeling Fluid Retention Abdomen Numbness Hands and Feet   Increased DHEA
Chemical Sensitivities Fluid Retention Extremities Painful Intercourse   Decreased DHEA
Cold Body Temperature Foggy Thinking Premenstrual Syndrome   Increased Cortisol
Cold Extremities Headaches Salt Craving   Decreased Cortisol
Confusion Heart Palpitations Sleep Disturbances   Increased Insulin
Constipation Heavy & Irregular Menses Swollen Eyes   Decreased Thyroid
Cramping Abdominal Hoarseness Tearfulness RATING SCALE Patient name:
Cravings for Sweet Hot Flashes Thinning Skin 0 No Symptom Email:
Decreased Concentration Hypoglycemia Tired But Wired 1 Very Mild Doctor:
Decreased Sex Drive Increased Facial  &/or Body Hair Urinary Incontinence 2 Mild Ph Number:  
Decreased Sexual Sensation Increased Hair Loss Vaginal Dryness 3 Moderate Please enter patient name and your email address so the results can be emailed to you
Decreased Stamina Irritability Weight Gain: Hips 4 Severe
Deepening of Voice Joint Pains Weight Gain: Waist 5 Very Severe