USING SYMPTOMS TO DETERMINE WHICH HORMONES TO TEST IN SALIVA 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 Form.Hot FlashesHot FlashesNoYesApathyApathyNoYesNervousNervousNoYesDecrease LibidoDecrease LibidoNoYesNight SweatsNight SweatsNoYesProstrate ProblemsProstrate ProblemsNoYesSleep DisturbancesSleep DisturbancesNoYesIrrirableIrrirableNoYesFoggy ThinkingFoggy ThinkingNoYesDecreased Urine FlowDecreased Urine FlowNoYesFatigueFatigueNoYesAnxiousAnxiousNoYesBone LossBone LossNoYesIncreased Urinary UrgeIncreased Urinary UrgeNoYesHeadachesHeadachesNoYesWeight gain-hipsWeight gain-hipsNoYesCheck 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.Decreased LibidoDecreased LibidoNoYesProstrate ProblemsProstrate ProblemsNoYesDecreased Muscle MassDecreased Muscle MassNoYesBurned Out FeelingBurned Out FeelingNoYesDecreased ErectionDecreased ErectionNoYesDecreased Mental SharpnessDecreased Mental SharpnessNoYesThinning SkinThinning SkinNoYesOily SkinOily SkinNoYesFatigueFatigueNoYesAcneAcneNoYesAches & PainAches & PainNoYesIncreased Joint PainIncreased Joint PainNoYesDecreased StaminaDecreased StaminaNoYesAggressionAggressionNoYesFoggy ThinkingFoggy ThinkingNoYesDepressedDepressedNoYesDecreased Urine FlowDecreased Urine FlowNoYesIrritableIrritableNoYesDecreased FlexibilityDecreased FlexibilityNoYesSleep DisturbancesSleep DisturbancesNoYesIncreased Urinary UrgeIncreased Urinary UrgeNoYesAnxiousAnxiousNoYesHeart PalipitationsHeart PalipitationsNoYesBone LossBone LossNoYesNervousNervousNoYesThose with symptoms in both categories above may want to test Hormone Profile I ( E2, Pg, T, DS, C). This 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 DisturbancesNoYesWebsiteSubmit
