Download Lifestages – Samaritan Centers For Women Symptoms List

Lifestages – Samaritan Centers For Women
Symptoms List
Name ________________________________ Date of Birth _______________________ Date ____________________
Hormones currently using ____________________________________________________________________________
Estrogen Deficiency
___ Hot Flashes
___ Night Sweats
___ Vaginal dryness
___ Low libido
___ Memory Lapses
___ Incontinence
___ Tearful/depression
___ Sleep disturbances
___ Heart palpitations
___ Bone loss
___ Aches/Pains
___ Anxiety
___ Thinning skin
___ Hair loss
Estrogen Excess
___ Mood swings (PMS)
___ Tender breasts
___ Water retention
___ Nervous/anxious
___ Irritable
___ Fibrocystic breasts
___ Uterine fibroids
___ Weight gain in hips
___ Headaches
___ Endometrial bleeding
___ Breast cancer
___ Uterine cancer
Progesterone Deficiency
___ Hot Flashes
___ Night Sweats
___ Vaginal dryness
___ Low libido
___ Memory Lapses
___ Incontinence
___ Tearful/depression
___ Sleep disturbances
___ Heart palpitations
___ Bone loss
___ Aches/Pains
___ Anxiety
___ Water retention
___ Yeast infection
___ Hair loss
Progesterone Excess
___ Sleepiness
___ Breast tenderness
___ Decreased libido
___ Mild depression
___ Yeast infection
___ Bloating
___ Water retention
Androgen Deficiency
___ Low libido
___ Vaginal dryness
___ Foggy thinking
___ Hot flashes
___ Night sweats
___ Aches/pains
___ Memory lapses
___ Incontinence
___ Depressed
___ Sleep disturbances
___ Decreased muscle
___ Bone loss
___ Thinning skin
___ Fibromyalgia
Androgen Excess
___ Excessive facial hair
___ Loss of scalp hair
___ Increased acne
___ Oily skin
___ Tender breasts
___ Anxiety
___ Ovarian cysts
Cortisol Deficiency
___ Fatigue
___ Sugar craving
___ Allergies
___ Asthma
___ Sinusitis
___ Chemical sensitivity
___ Stress
___ Aches/pains
___ Arthritis
___ Neck/back pain
___ Muscle stiffness
___ Hives/itching
___ Fibromyalgia
___ Low blood pressure
Cortisol Excess
___ Sleep disturbances
___ Bone loss
___ Fatigue
___ Weight gain waist
___ Loss of muscle mass
___ Thinning skin
___ Anxiety
___ Stress
___ Sugar Craving
___ Memory lapse
___ Hot flashes
Thyroid Deficiency
___ Basal Body temp <97
___ Fatigue
___ Lack of endurance
___ Dizziness
___ Joint stiffness
___ Depression
___ Anxiety
___ Decreased concentration
___ Muscle weakness
___ Headaches
___ PMS
___ Mood swings
___ Irritability
___ Word mix-ups
___ Joint pain/aches
___ Swollen fingers
___ Brain fog
___ Memory blanks
Thyroid Excess
___ Weight loss/gain
___ Fatigue
___ Shakiness
___ Heat intolerant
___ Restlessness
___ Increased thirst
___ Hair loss
___ Anemia
___ Increased sweating
___ Hives/itching
___ Brittle nails
___ Rapid heartbeat
___ Chest pain
___ Shortness of breath
___ Weakness
___ Decreased muscle mass
___ Irregular menstrual cycles
___ Anxiety/panic attacks
___ Depression/irritability
___ Emotional swings/ aggression
For office use only:
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Orders:
Sig: ____________________________________ Disp #_______RF___
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Sig: ____________________________________ Disp #_______RF___
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Sig: ____________________________________ Disp #_______RF___
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Signature ________________________________ Date______________
4/21/14