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Hormone Questionnaire

Prior Lake / Savage Chiropractic
Health and Wellness Center
14020 South Hwy 13 #650
Savage, MN 55372

952-447-8980

If you have further questions following this self care questionnaire a complete in office health assessment is available for a $35.00 fee. Call the office today to schedule your specific evaluation assessment.

Instructions:

Each question below is assigned a value. After you finish each section score that section. If your score is above the maximum acceptable level that specific hormone system may be in trouble.

Patient Name:__________________________________

Is your Adrenal Gland fatigued?

  1. 4 Pts. YES NO Do you get frazzled easily or fly off the handle easily?

  2. 3 Pts. YES NO Do you startle easily and/ or have low tolerance for loud noises?

  3. 4 Pts. YES NO Do you have a low stamina for stress and/ or cave in easily?

  4. 3 Pts. YES NO Do you have unusual fatigue, especially in the morning and/ or have more energy at night?

  5. 4 Pts. Yes No Do you notice swollen ankle about one hour after getting up?

  6. 4 Pts. YES NO Do you feel tired but wired and/ or have low reserve to meet any type of challenge?

  7. 2 Pts. YES NO Do you have salt cravings?

  8. 3 Pts. YES NO Do you get cranky/ tired if you skip a meal and find you have to eat frequently?

  9. 2 Pts. YES NO Do you have excess sensitivities to chemicals and/ or increased allergies?

  10. 2 Pts. YES NO Do you have low tolerance for alcohol, caffeine, other drugs or strong odors?

  11. 2 Pts. YES NO Do you have dizziness upon standing or low blood pressure?

*Total____; If your score is more than 15, then you may some degree of Adrenal Fatigue

*Labs to consider: Adrenal Stress Index (4 salivary Cortisol levels, DHEA, Insulin, 17-OH Progesterone levels)

*Supplements to help with low Adrenal function are available at our office upon request, Call our office today for your specific supplements and evaluation needs: 952-447-8980



Are your Sex Hormones Unbalanced (FEMALES)

  1. 4 pts. Yes No Do you have premenstrual mood swings?

  2. 4 pts. Yes No Do you have premenstrual or menopausal food cravings?

  3. 4 pts. Yes No Do you experience irregular periods?

  4. 3 pts. Yes No Have you ever experienced a miscarriage, an abortion, or infertility?

  5. 4 pts. Yes No Have you used birth control pills or other hormone medication?

  6. 3 pts. Yes No Do you have uncomfortable periods-cramps, lengthy or heavy bleeding, or sore breasts?

  7. 4 pts. Yes No Do you get Peri- or postmenopausal discomfort (hot flashes, sweats, insomnia or mental dullness)?

  8. 3 pts. Yes No Do you experience skin eruptions with period?

*Total_____; If your score is more than 6, then you most likely have an imbalance with your Progesterone and Estrogen levels which are contributing to you not feeling well
*Labs to consider: Salivary Hormone Testing
*There are specific Supplements available to address and help balance your Sex Hormones: Natural Progesterone, Natural Estrogen: Call our office today for your specific supplements and evaluation needs: 952-447-8980

Are your Sex Hormones Unbalanced? (MALES)

  1. 4 pts. Yes No Do you have low libido (sex drive)?

  2. 4 pts. Yes No Do you have erection difficulties?

  3. 3 pts. Yes No Do have premature ejaculation?

  4. 3 pts. Yes No Do you have a decrease in muscle strength recently?

  5. 2 pts. Yes No Do you have frequent urination at night?

  6. 2 pts. Yes No Do you feel depressed recently?

*Total_____; If your score is more than 8, then you may have low testosterone or low precursors to testosterone
*Labs to consider: Salivary Hormone Testing
* Supplements to help balance your Sex Hormones: Testosterone, Call our office today for your specific needs: 952-447-8980

Is Your Thyroid Underactive?

  1. 4 pts. Yes No Do you experience low energy?

  2. 4 pts. Yes No Are you easily chilled (especially hands and feet)?

  3. 4 pts. Yes No Do other family members have thyroid problems?

  4. 4 pts. Yes No Can you gain weight without overeating; hard to lose excess weight?

  5. 3 pts. Yes No Do you have to force yourself to do even moderate exercise?

  6. 4 pts. Yes No Do you find it hard to get going in the morning?

  7. 3 pts. Yes No Do you have high cholesterol?

  8. 3 pts. Yes No Do you have low blood pressure?

  9. 4 pts. Yes No Did you gain weight near the start of menses, a pregnancy, or menopause?

  10. 3 pts. Yes No Do you get chronic headaches?

  11. 3 pts. Yes No Do you use food, caffeine, tobacco, and/or other stimulants to get going?

*Total______; If your score is more than 15, than your Thyroid is probably causing your low energy and mood
*Labs to consider: Amino Acid Levels, Neurotransmitter Levels, Serum Thyroid levels (T4, T3)
*Supplements to help boost Thyroid are available at our office upon request, Call our office today for your specific supplements and evaluation needs: 952-447-8980

Are you deficient in DHEA?

  1. 4 pts. YES NO My libido is low

  2. 3 pts. YES NO My body does not have a special scent during sexual arousal

  3. 3 pts. YES NO My belly is getting fat

  4. 2 pts. YES NO My muscles are flabby

  5. 2 pts. YES NO My hair is dry

  6. 3 pts. YES NO My skin and eyes are dry

*Total____; If your score is more than 10, than you probably have a DHEA deficiency
*Labs to consider: Salivary DHEA levels or Serum DHEA-S levels
*Supplements to help boost DHEA are available at our office upon request, Call our office today for your specific supplements and evaluation needs: 952-447-8980

Are you deficient in Pregnenolone?

  1. 4 pts. YES NO I have memory loss

  2. 4 pts. YES NO I feel drained and have a hard time handling stress

  3. 3 pts. YES NO My joints hurt most of the time

  4. 3 pts. YES NO I have lost interest in art and/ or music

  5. 2 pts. YES NO I don't see colors as brightly as I used to

  6. 2 pts. YES NO I have low blood pressure

  7. 2 pts. YES NO I have cravings for salt and salty foods

*Total____; If your score is more than 11, than you are probably deficient in Pregnenolone
*Labs to consider: Salivary 17-OH Progesterone level; Serum Pregnenolone level
*Supplements to help boost Pregnenolone are available at our office upon request, Call our office today for your specific supplements and evaluation needs: 952-447-8980 Natural Pregnenolone, B-complex vitamins

Are you deficient in Melatonin?

  1. 4 pts. YES NO I look older than I am

  2. 4 pts. YES NO I have trouble falling asleep or staying asleep

  3. 3 pts. YES NO When I get up in the morning, I don't feel rested

  4. 3 pts. YES NO I feel as if I am always going to bed late and waking up late

  5. 2 pts. YES NO I cannot tolerate jet-lag

*Total____; If your score is more than 9, than you probably have a Melatonin deficiency
*Supplements to help boost Melatonin levels: Natural Melatonin, L-Tryptophan, 5-HTP: these supplements are available at our office upon request, Call our office today for your specific supplements and evaluation needs: 952-447-8980