Download Do You Have A Hormone Deficiency

Do You Have A Hormone Deficiency?
Thierry Hertoghe M.D. developed this self-test to help you
determine if your levels of hormones are below normal. This is
designed to help you and your doctor select the correct treatment for
you. Circle the score for each line then total the score at the bottom
of each hormone. Bring this form to your doctor after you have
filled this out.
PROGESTERONE
1
2
3
4
ESTROGEN
1
2
3
4
5
6
7
8
9
10
11
Signs & Symptoms
I am losing hair on top of my
head.
I’m getting thin, vertical
wrinkles above my lips
My breasts are droopy
My face is too hairy
My eyes are dried and easily
irritated
I have hot flashes
I fell tired constantly
I am depressed
My menstrual flow is light
My cycles are irregular, too
short, or too long
Women without periods: I do
not feel like making love
anymore
Never
0
1 2
Always
3 4
0
1 2
3 4
0
0
0
1 2 3 4
1 2 3 4
1 2 3 4
0
0
0
0
0
1
1
1
1
1
0
1 2
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
3 4
5
6
7
8
9
10
Signs & Symptoms
My breast are large
My close friends complain I’m
nervous and agitated
I feel anxious
I sleep lightly and restlessly
The following questions are
for women who have not yet
reached menopause, and
menopausal women who are
taking hormone replacement
therapy
My breasts are swollen and
tender or painful before my
period
My lower belly is swollen
I am irritable and aggressive
I loose my self-control
I have heavy periods
They are continuously painful
Never
0
0
1 2
1 2
Always
3 4
3 4
0
0
1 2
1 2
3 4
3 4
0
1 2
3 4
0
0
0
0
0
1
1
1
1
1
3
3
3
3
3
2
2
2
2
2
4
4
4
4
4
Add up your Overall Score_____ Post-menopause women not
treated with hormone replacement therapy: 4 or less: Satisfactory
level. Between 5 and 8: Possible progesterone deficiency. 9 or more:
Probable progesterone deficiency. Menopausal women taking
hormone replacement therapy: 10 or less: Satisfactory level.
Between 11-20: Possible progesterone deficiency. 21 or more:
Probable progesterone deficiency.
Add up your Overall Score_____: Overall total is 10 or less is
satisfactory level. Between 11-20: Possible Estrogen deficiency. 21
or more: Probable Estrogen deficiency
TESTOSTERONE
GROWTH HORMONE
1
2
3
4
5
6
7
8
9
10
Signs & Symptoms
My hair is thinning
My cheeks sag
My abdomen are receding
My abdomen is flabby
My muscles are slack
My skin is thin and /or dry
It’s hard to recover after
physical activity
I feel exhausted
I don’t like the world. I tend to
isolate myself
I feel continuously anxious
Never
0
0
0
0
0
0
0
1
1
1
1
1
1
1
0
0
1 2
1 2
3 4
3 4
0
1 2
3 4
2 3
2 3
2 3
2 3
2 3
2 3
2 3
Always
4
4
4
4
4
4
4
Add up your Overall Score_____: Overall total is 10 or less is
satisfactory level. Between 11-20: Possible Growth Hormone
deficiency. 21 or more: Probable Growth Hormone deficiency
1
2
3
4
5
6
7
8
9
10
Signs & Symptoms
My face has gotten slack and
more wrinkled
I’ve lost muscle tone
My belly tends to get fat
I’m constantly tired
I feel like making love less
often than I used to
MEN ONLY
My breasts are getting fatty
I feel less confident and more
hesitant
My sexual performance is
poorer than it used to be
I have hot flashes and sweats
I tire easily with physical
activity
Never
0
1 2
Always
3 4
0
0
0
0
1
1
1
1
3
3
3
3
0
0
0
1 2
1 2
1 2
3 4
3 4
3 4
0
1 2
3 4
0
0
1 2
1 2
3 4
3 4
2
2
2
2
4
4
4
4
Add up your Overall Score_____: For women: 5 or less is
satisfactory level. Between 6-10: Possible Testosterone deficiency.
11 or more: Probable Testosterone deficiency. For men: 10 or less is
satisfactory level. Between 11-20: Possible Testosterone deficiency.
21 or more: Probable Testosterone deficiency.
PART II – Circle the answer to the ailments and discuss them
with your physician.
DHEA
1
2
3
4
5
6
7
8
9
10
Signs & Symptoms
My hair is dry
My skin and eyes are dry
My muscles are flabby
My belly is getting fat
I don’t have much hair under
my arm
I don’t have much hair in my
pubic area
I don’t have much tissue in the
pubic area
My body doesn’t have much
of a special scent during
sexual arousal
I cant tolerate noise
My libido is low
Never
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
Always
4
4
4
4
4
0
1 2
3 4
0
1 2
3 4
0
1 2
3 4
0
0
1 2
1 2
3 4
3 4
Energy
1 Do you have a hard time getting up in
the morning?
2 Do you always feel tired in the
afternoon?
YES
NO
YES
NO
1 Do you lack sexual desire?
2 Does your penis or clitoris seem less
sensitive?
3 Are your erections not firm enough?
4 Have you lost your attraction toward
your partner?
5 Do you lack vaginal lubrication?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
1 Do you sleep poorly?
2 Do you rarely dream?
YES
NO
YES
NO
1 Do you suffer from short -or longterm memory loss?
2 Do you have trouble concentrating?
YES
NO
YES
NO
1 Wrinkles on your face along the nose,
smile lines, forehead creases?
2 Do you have little wrinkles around the
eyes and crows feet?
3 Do you have age spots?
4 Do you have dry, thin skin?
5 Are you loosing your hair or is it
turning grey?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
1 Is your abdomen too plump? Is it
distended?
2 Women: Are your breasts too large, do
they get larger before your periods?
3 Are your buttocks and thighs too well
padded? Are you pear shaped?
YES
NO
YES
NO
YES
NO
1
2
3
4
5
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Sex
Sleep
Memory
Add up your Overall Score_____: Overall total is 10 or less is
satisfactory level. Between 11-20: Possible DHEA deficiency. 21 or
more: Probable DHEA deficiency
Skin &
Hair
THYROID
1
2
3
4
5
6
7
8
9
10
Signs & Symptoms
I’m sensitive to cold
My hands and feet are always
cold
In the morning my face is
puffy and my eyelids are
swollen
I put on weight easily
I have dry skin
I have trouble getting up in the
morning
I feel more tired at rest than
when I’m active
I am constipated
My joints are stiff in the
morning
I feel like I’m living in slow
motion
Never
0
0
1 2
1 2
Always
3 4
3 4
0
1 2
3 4
0
0
0
1 2
1 2
1 2
3 4
3 4
3 4
0
1 2
3 4
0
0
1 2
1 2
3 4
3 4
0
1 2
Weight
Control
Stress &
Mood
3 4
Add up your Overall Score_____: Overall total is 10 or less is
satisfactory level. Between 11-20: Possible Thyroid deficiency. 21
or more: Probable Thyroid deficiency
Do you suffer from constant fatigue?
Do you have high blood pressure?
Are you anxious, nervous, or irritable?
Do small things set you off?
Are you depressed?
Joints &
Bones
1
2
3
4
Do you have arthritis?
Do you have osteoarthritis in the lip?
Do you have sharp shoulder pain?
Have you lost muscle mass, tone, and
strength?
5 Do you have bones loss of the spine,
hips, hands, wrist, and feet?