Hormonal Symptom/Relief Checklist

Symptom/Relief Checklist

The following is a checklist of symptoms associated with a decline in natural hormones. Place a check in the box next to the symptom if you experience it. After completing a 6-week trial program, re-evaluate your symptoms for comparison.

Symptom	1st Office Visit (Pre-treatment)	3rd Office Visit (Symptom Relief)	4th Office Visit (Symptom Relief)
Forgetfulness	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Headaches	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Inability to concentrate	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Memory loss	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Word searching	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Crying spells	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Depression	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Heart palpitations	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Insomnia	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Irritability	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Loss of interest in most things	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Panic attacks	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Inability to deal with stressful situations	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Worry needlessly	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Backache	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Fatigue/Lethargy	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Joint pain	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Burning with urination	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Urine leakage	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Irritable bowel problems	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Decreased sexual desire	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Painful intercourse	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Vaginal dryness	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Dry eyes	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Dry skin	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Hot flashes/ night sweats	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Skin crawling	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Breast pain	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Cold hands and feet	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone
Weight gain	¨ Yes ¨ No	¨ Improved ¨ Gone	¨ Improved ¨ Gone