Hormone Questionnaires
Print off this form and return to our office for analysis
Prior Lake / Savage Chiropractic
Health and Wellness Center
14020 South Hwy 13 #650
Savage, MN 55372
952-447-8980
If you have further questions following this self care questionnaire a complete in office health assessment is available. Call the office today to schedule your specific evaluation assessment.
Instructions
Each question below is assigned a value. After you finish each section score that section. If your score is above the maximum acceptable level that specific hormone system may be in trouble.
Patient Name:__________________________________
Is your Adrenal Gland fatigued?
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4 Pts. YES NO Do you get frazzled easily or fly off the handle easily?
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3 Pts. YES NO Do you startle easily and/ or have low tolerance for loud noises?
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4 Pts. YES NO Do you have a low stamina for stress and/ or cave in easily?
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3 Pts. YES NO Do you have unusual fatigue, especially in the morning and/ or have more energy at night?
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4 Pts. Yes No Do you notice swollen ankle about one hour after getting up?
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4 Pts. YES NO Do you feel tired but wired and/ or have low reserve to meet any type of challenge?
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2 Pts. YES NO Do you have salt cravings?
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3 Pts. YES NO Do you get cranky/ tired if you skip a meal and find you have to eat frequently?
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2 Pts. YES NO Do you have excess sensitivities to chemicals and/ or increased allergies?
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2 Pts. YES NO Do you have low tolerance for alcohol, caffeine, other drugs or strong odors?
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2 Pts. YES NO Do you have dizziness upon standing or low blood pressure?
*Total_____. If your score is more than 15, then you may have some degree of Adrenal Fatigue.
*Labs to consider: Adrenal Stress Index (4 salivary Cortisoll levels, DHEA, Insulin, 17-OH Progesterone levels)
*Supplemenets to help with low adrenal function are available at our office upon request. Call our office today for your specific supplements and evaluation needs: 952-447-8980.
Are your Sex Hormones Unbalanced (FEMALES)
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4 pts. Yes No Do you have premenstrual mood swings?
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4 pts. Yes No Do you have premenstrual or menopausal food cravings?
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4 pts. Yes No Do you experience irregular periods?
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3 pts. Yes No Have you ever experienced a miscarriage, an abortion, or infertility?
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4 pts. Yes No Have you used birth control pills or other hormone medication?
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3 pts. Yes No Do you have uncomfortable periods-cramps, lengthy or heavy bleeding, or sore breasts?
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4 pts. Yes No Do you get Peri- or postmenopausal discomfort (hot flashes, sweats, insomnia or mental dullness)?
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3 pts. Yes No Do you experience skin eruptions with period?
*Total_____. If your score is more than 6, then you most likely have an imbalance with your Progesterone and Estrogen levels which are contributing to you not feeling well.
*Labs to consider: Salivary Hormone Testing
*There are specific Supplements available to address and help balance your Sex Hormones: Natural Progesterone, Natural Estrogen. Call our office today for your specific supplements and evaluation needs: 952-447-8980.
Are your Sex Hormones Unbalanced? (MALES)
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4 pts. Yes No Do you have low libido (sex drive)?
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4 pts. Yes No Do you have erection difficulties?
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3 pts. Yes No Do have premature ejaculation?
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3 pts. Yes No Do you have a decrease in muscle strength recently?
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2 pts. Yes No Do you have frequent urination at night?
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2 pts. Yes No Do you feel depressed recently?
*Total_____. If your score is more than 8, then you may have low testosterone or low precursors to testosterone.
*Labs to consider: Salivary Hormone Testing
* Supplements to help balance your Sex Hormones: Testosterone. Call our office today for your specific needs: 952-447-8980.
Is Your Thyroid Underactive?
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4 pts. Yes No Do you experience low energy?
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4 pts. Yes No Are you easily chilled (especially hands and feet)?
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4 pts. Yes No Do other family members have thyroid problems?
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4 pts. Yes No Can you gain weight without overeating; hard to lose excess weight?
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3 pts. Yes No Do you have to force yourself to do even moderate exercise?
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4 pts. Yes No Do you find it hard to get going in the morning?
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3 pts. Yes No Do you have high cholesterol?
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3 pts. Yes No Do you have low blood pressure?
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4 pts. Yes No Did you gain weight near the start of menses, a pregnancy, or menopause?
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3 pts. Yes No Do you get chronic headaches?
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3 pts. Yes No Do you use food, caffeine, tobacco, and/or other stimulants to get going?
*Total______. If your score is more than 15, than your Thyroid is probably causing your low energy and mood.
*Labs to consider: Amino Acid Levels, Neurotransmitter Levels, Serum Thyroid levels (T4, T3)
*Supplements to help boost Thyroid are available at our office upon request. Call our office today for your specific supplements and evaluation needs: 952-447-8980.
Are you deficient in DHEA?
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4 pts. YES NO My libido is low
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3 pts. YES NO My body does not have a special scent during sexual arousal
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3 pts. YES NO My belly is getting fat
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2 pts. YES NO My muscles are flabby
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2 pts. YES NO My hair is dry
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3 pts. YES NO My skin and eyes are dry
*Total____. If your score is more than 10, than you probably have a DHEA deficiency.
*Labs to consider: Salivary DHEA levels or Serum DHEA-S levels
*Supplements to help boost DHEA are available at our office upon request. Call our office today for your specific supplements and evaluation needs: 952-447-8980.
Are you deficient in Pregnenolone?
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4 pts. YES NO I have memory loss
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4 pts. YES NO I feel drained and have a hard time handling stress
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3 pts. YES NO My joints hurt most of the time
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3 pts. YES NO I have lost interest in art and/ or music
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2 pts. YES NO I don't see colors as brightly as I used to
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2 pts. YES NO I have low blood pressure
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2 pts. YES NO I have cravings for salt and salty foods
*Total____. If your score is more than 11, than you are probably deficient in Pregnenolone.
*Labs to consider: Salivary 17-OH Progesterone level; Serum Pregnenolone level
*Supplements to help boost Pregnenolone are available at our office upon request. Call our office today for your specific supplements and evaluation needs: 952-447-8980 Natural Pregnenolone, B-complex vitamins.
Are you deficient in Melatonin?
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4 pts. YES NO I look older than I am
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4 pts. YES NO I have trouble falling asleep or staying asleep
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3 pts. YES NO When I get up in the morning, I don't feel rested
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3 pts. YES NO I feel as if I am always going to bed late and waking up late
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2 pts. YES NO I cannot tolerate jet-lag
*Total____. If your score is more than 9, than you probably have a Melatonin deficiency.
*Supplements to help boost Melatonin levels: Natural Melatonin, L-Tryptophan, 5-HTP: these supplements are available at our office upon request.
Call our office today for your specific supplements and evaluation needs: 952-447-8980.