Checklist for Symptoms of Hormone Imbalance
FOR MEN
The following checklists can be used to help you and your healthcare provider determine specific symptoms of hormone imbalance.
Category 1: Basic Hormone Imbalance
Mark which of the following symptoms are troublesome and/or persist over time.
Burned out feeling
Irritable
Hot flashes
Erectile dysfunction
Weight gain waist
Prostate problems
Decreased libido
Decreased mental sharpness
Night sweats
Insomnia
Decreased urine flow
Increased urinary urge
Decreased stamina
Infertility problems
Sleep disturbances
Oily skin
Decreased muscle mass
Apathy
Number selected
Category 2: Adrenal Hormone Imbalance
Mark which of the following symptoms are troublesome and/or persist over time.
Aches and pains
Elevated triglercerides
Sleep disturbances
Depression
Infertility
Lack of motivation
Chronic illness
Prostate problems
Stress
Evening fatigue
Morning fatigue
Bone loss
Anxiety
Blood sugar imbalance
Allergic conditions
Autoimmune illness
Weight gain waist
Fibromyalgia
Decreased erections
Susceptibility to infections
Number selected
Category 3: Thyroid Hormone Imbalance
Mark which of the following symptoms are troublesome and/or persist over time.
Low libido
Depression
Foggy thinking
Infertility
Constipation
Fatigue
Elevated cholesterol
Cold body temperature
Decreased erections
Headaches
Sleep disturbances
Lack of motivation
Inability to lose weight
Number selected
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