Checklist for Symptoms of Hormone Imbalance
FOR WOMEN
The following checklists can be used to help you and your healthcare provider determine specific symptoms of hormone imbalance.
Category 1: Basic Hormone Imbalance
Note which of the following symptoms are troublesome and/or persist over time.
Hot flashes
Mood swings (PMS)
Heart palpitations
Cystic ovaries
Heavy menses
Foggy thinking
Fibrocystic breasts
Foggy thinking
Thinning skin
Uterine fibroids
Urinary incontinence
Night sweats
Vaginal dryness
Acne
Weight gain
Depressed mood
Increased body/facial
Headaches
Bone loss
Number selected
Category 2: Adrenal Hormone Imbalance
Note which of the following symptoms are troublesome and/or persist over time.
Aches and pains
Elevated triglercerides
Sleep disturbances
Depression
Infertility
Nervousness
Chronic illness
Evening fatigue
Morning fatigue
Bone loss
Anxiety
Blood sugar imbalance
Allergic conditions
Autoimmune illness
Susceptibility to infections
Number selected
Category 3: Thyroid Hormone Imbalance
Note which of the following symptoms are troublesome and/or persist over time.
Aches and pains
Anxiety
Dry skin
Cold hands and feet
Fatigue
Foggy thinking
Heart palpitations
Low libido
Constipation
Thinning hair
Brittle nails
Depression
Headaches
Infertility
Weight gain
Feeling cold all the time
Inability to lose weight
Sleep disturbances
Menstrual irregularities
Elevated cholesterol
Number selected
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