Welcome to Hormone Balance Evaluation for WOMEN! We are about to ask you a few simple questions to help us estimate how balanced your key hormones may be. Let's get started! How is your Energy Level? Like an Energizer Bunny Tired but enough to get through the day Too tired after work for anything Barely make it through the day How is your mood? Happy-go-lucky most of the time Even, neither bad nor good Mood siwngs, ups and downs Sad and depressed a lot How is your mental sharpness? I am pretty sharp, no complaints I think I used to be smarter It's getting harder to keep up with others Constant brain fog. I've never been like that! Do you get hot flashes and/or night sweats? Never Occasionally Regularly (once a week or less) Frequently (more than once a week) How is your sex drive? Same I had for years OK but less than what it used to be 5 years ago Definitely decreased Nonexistent How is your sleep? Good, I feel fully rested in the morning I sleep every night but don't feel it's enough I have trouble falling asleep, wake up often It's a constant struggle; I feel exhausted in the morning How often you feel cold without a reason? Never Sometimes Often Constantly: I never seem to be able to get warm Losing hair or brittle hair? Nothing unusual It's getting noticeably worse I am beginning to really worry about my hair loss and breakage It's a disaster! My hair is falling out every day! Skin getting dry and/or winkled? Nothing beyond what I consider normal for my age More than I am willing to accept but nothing serious I think my skin is beginning to look much older than my age The way my skin looks is really worrisome, and it's only getting worse. How are your body weight and shape? I haven't noticed any recent changes in my weight or the way I look I've gained a few pounds but in "all the right places" I've gained quite a few pounds especially around midsection I've gained a lot of weight and my body shape has changed a lot (big belly, smaller hips, batwings, etc.) What is your age? 18-35 36-45 46-55 56 + Captcha. Enter the following text: That's it! To ensure privacy, we'll send you results via email. Your First Name Your Email I agree to receive the results of this evaluation and other communication from CT Hormone Therapy and Integrative MD via email. Time's up
