USING SYMPTOMS TO DETERMINE WHICH HORMONES TO TEST IN SALIVA Please select the appropriate option. Name *FirstLastGender *Age *Phone *Email *FOR HORMON IMBALANCECheck which of these symptoms are troublesome and persist over time. Two or more symptoms are an indication of the need to test both Estradiol (E2) & Progesterone (Pg). These can be selected at the bottom of the Requisition FormHot FlashesHot FlashesNoYesHeart PalpitationsHeart PalpitationsNoYesIrritable Irritable NoYesCystic OveriesCystic OveriesNoYesNight Sweats Night Sweats NoYesBone LossBone LossNoYesAnxiousAnxiousNoYesHeavy MensesHeavy MensesNoYesVaginal DrynessVaginal DrynessNoYesHeadachesHeadachesNoYesFibrocystic Breasts Fibrocystic Breasts NoYesFoggy ThinkingFoggy ThinkingNoYesMood Swings(PMS)Mood Swings(PMS)NoYesUterine FibroidsUterine FibroidsNoYesElevated TriglyceridesElevated TriglyceridesNoYesMemory LapsesMemory LapsesNoYesTender BreastsTender BreastsNoYesWeight GainWeight GainNoYesDecreased LibidoDecreased LibidoNoYesTearfulTearfulNoYesWater RetentionWater RetentionNoYesBleeding ChangesBleeding ChangesNoYesCold Body TempCold Body TempNoYesDepressedDepressed NoYesSleep DisturbancesSleep DisturbancesNoYesIncontinence Incontinence NoYesCheck which of these symptoms are troublesome & persist over time. For two or more symptoms, Testosterone (T) & DHEAS (DS) Testing is recommended. These can be selected at the bottom of the Requisition Form.Increased Facial HairsIncreased Facial HairsNoYesOvarian CystsOvarian CystsNoYesDecreased Muscle MassDecreased Muscle MassNoYesIncreased Body HairIncreased Body HairNoYesElevated TriglyceridesElevated TriglyceridesNoYesLoss of Scalp HairLoss of Scalp HairNoYesSleep DisturbancesSleep DisturbancesNoYesFoggy ThinkingFoggy ThinkingNoYesHeart PalpitationsHeart PalpitationsNoYesAcneAcneNoYesDecreased LibidoDecreased LibidoNoYesIncontinenceIncontinenceNoYesHeadachesHeadachesNoYesOily SkinOily SkinNoYesVagainal DrynessVagainal DrynessNoYesDepressedDepressedNoYesFibromyalgiaFibromyalgiaNoYesIrritableIrritableNoYesBonelossBonelossNoYesNervousNervousNoYesAnxiousAnxiousNoYesThining SkinThining SkinNoYesNervousNervousNoYesThose with symptoms in both categories above may want to test Hormone Profile I ( E2, Pg, T, DS, C) or Hormone Profile II ( E2, Pg, T, DS, Cx2). If there is a history of breast Cancer, Hormone Profile II is recommended. Profiles can be selected at the end of the Requisition Form.ADRENAL IMBALANCECheck which of these symptoms are troublesome & persist over time. For two or more symptoms are an indication that testing Cortisol (C) for Adrenal Imbalance is recommended. This can be selected at the bottom of the Requisition Form.FatiqueFatiqueNoYesAnxiousAnxiousNoYesHair LossHair LossNoYesChemical SensitivityChemical SensitivityNoYesWeight Gain-WaistWeight Gain-WaistNoYesMemory LapsesMemory LapsesNoYesIncreased Facial HairIncreased Facial HairNoYesStressStressNoYesDecreased Muscle MassDecreased Muscle MassNoYesDepressedDepressedNoYesIncreased Body HairIncreased Body HairNoYesCold Body TemperatureCold Body TemperatureNoYesThinning SkinThinning SkinNoYesHeadachesHeadachesNoYesSugar CravingsSugar CravingsNoYesAches & PainAches & PainNoYesElevated TriglyceridesElevated TriglyceridesNoYesDecreased LibidoDecreased LibidoNoYesAllergiesAllergiesNoYesIrritableIrritableNoYesSleep DisturbancesSleep DisturbancesNoYesCommentSubmit
