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Please answer all questions.
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Birth Date
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
January
February
March
April
May
June
July
August
September
October
November
December
Month
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Height
*
cm
Weight
*
kg
Gender
*
Female
Male
Are you
*
Pre-menopause
Menopausal
Post-menopause
Estrogen Sensitivity
How did you feel when you were 35?
KEY:
3 = Predominantly first option
2 = In between, average
1 = Predominantly second option
Dense breasts, breast cysts OR Droopy, non-dense breasts
*
3
2
1
High colour, rubenesque, healthy hair OR More athletic build, oily dull hair
*
3
2
1
Heavy periods, breast tenderness pre menses OR Irregular menstruation with light or irregular periods
*
3
2
1
Total Estrogen Sensitivity
How do you feel now?
KEY: 3 = Severe | 2 = Moderate | 1 = Mild | 0 = Not at all/not applicable
Nervous and agitated
3
2
1
0
Anxious
3
2
1
0
Weight gain
3
2
1
0
Poor sleep, insomnia
3
2
1
0
Swollen and reddish face
3
2
1
0
Increased abdominal fat
3
2
1
0
Bloating
3
2
1
0
Swollen feet and ankles
3
2
1
0
Loss of self-control
3
2
1
0
Total Progesterone Deficiency
Losing hair on top of head
3
2
1
0
Thin vertical wrinkles above lips
3
2
1
0
Droopy breasts
3
2
1
0
Hair on face
3
2
1
0
Eyes dry and easily irritated
3
2
1
0
Poor memory / foggy thinking
3
2
1
0
Decreased concentration
3
2
1
0
Night sweats
3
2
1
0
Hot flashes
3
2
1
0
Constant tiredness
3
2
1
0
Vaginal dryness
3
2
1
0
Depressed
3
2
1
0
Low libido
3
2
1
0
Total Estrogen Deficiency
Face slack/wrinkled
3
2
1
0
Bone density loss
3
2
1
0
Anxiety
3
2
1
0
Loss of libido
3
2
1
0
Reduced muscle tone
3
2
1
0
Expanded waistline
3
2
1
0
Cellulite on thighs
3
2
1
0
Varicose veins
3
2
1
0
Constant tiredness/post exercise exhaustion
3
2
1
0
Hesitant, undecided loss of self confidence
3
2
1
0
Excessive emotions
3
2
1
0
Loss of nipple/clitoral sensitivity
3
2
1
0
Total Testosterone Deficiency
How do you feel now?
KEY: 3 = Severe | 2 = Moderate | 1 = Mild | 0 = Not at all/not applicable
Fatigue
3
2
1
0
Permanent fatigue increasing with exercise
3
2
1
0
Muscle pain/ nerve tenseness
3
2
1
0
Reduced muscle strength
3
2
1
0
Persistent depression
3
2
1
0
Irritability
3
2
1
0
Increased aggression
3
2
1
0
Anxiety and fear
3
2
1
0
Hypochondria - frequent illness
3
2
1
0
Loss of self confidence
3
2
1
0
Poor libido - reduced sexual desire
3
2
1
0
Erection firmness, persistence, frequency reduced
3
2
1
0
Difficulty reaching climax
3
2
1
0
Reduced ejaculation volume
3
2
1
0
Reduced memory function
3
2
1
0
Increased sensitivity to pain
3
2
1
0
Increased expression of pain
3
2
1
0
Insomnia or reduced sleep
3
2
1
0
Hot flushes
3
2
1
0
Sweating spells (head and upper chest)
3
2
1
0
Enlarged prostate
3
2
1
0
Difficulty or frequent urination
3
2
1
0
Osteo arthritis/ joint pain
3
2
1
0
Total Testosterone Deficiency (Male)
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