Health Evaluation Questionaire

Please recognize and tick any/all symptoms below. Sharing this information with us will allow us to design a program that will help relieve or remove your symptoms.
All ill-health symptoms due to the ageing process… is your body’s signal that it is out of balance.  Healthy Hormones offers an Education, Nutrition and Lifestyle Coaching Program that will teach you the rules necessary to put your body back into balance.  Recognizing your symptoms is the first step ………. Congratulations!
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DIGESTIVE TRACT
Nausea or Vomiting
Diarrhea
Constipation
Bloating
Belching or passing Gas
Iintestinal/Stomach pain		 MIND
Poor Memory
Confusion, Poor Comprehension
Poor Concentration
Poor Physical Co-ordination
Difficulty in making Decisions
Stuttering or Stammering
Slurred Speech
Learning Disabilities
EMOTIONS
Mood Swings...Sad and/or Grumpy
Anxiety, Fear or Nervousness
Anger, Irritability or Aggressiveness
Depression
Emotional Outbursts		 ENERGY
Fatigue or Sluggishness
Apathy, Lethargy
Hyperactivity
Restlessness
Decrease in Strength/Endurance
EARS
Itchy Ears
Earaches, Ear Infections
Drainage from Ears
Ringing in Ears, Hearing Loss 		SKIN
Acne
Hives, Rashes or Dry Skin
Hairloss
Flushing or Hotflushes
Excessive Sweating
LUNGS
Chest Congestion
Asthma, Bronchitis
Shortness of Breath
Difficulty Breathing		 WEIGHT
Binge Eating/Drinking
Craving Certain Foods
Excessive Weight
Compulsive Eating
Water Retention
Loss in Weight
JOINTS/MUSCLES
Pain or Aches in Joints
Arthritis
Stiffness or Limitation of Movement
Pain or Aches in Muscles
Feeling Weakness or Tiredness
Back Pain		 EYES
Watery or Iitchy Eyes
Swollen, Reddened or Sticky Eyelids
Bags or Dark Circles under Eyes
Blurred or Tunnel Vision
HEART
Irregular or Skipped Heartbeat
Rapid or Pounding Heart
Chest Pain		 SLEEP
Insomnia
Falling Asleep After Dinner
MOUTH/THROAT
Chronic Coughing
Gagging, Frequent Need to Clear Throat
Sore Throat, Hoarseness or Loss of Voice
Swollen or Discolored Tongue
Bleeding Gums/Lips
Mouth Ulcers
Cold Sores 		OTHER
Fibroids
Cysts
Leaking Breast
Lack of Libido
Migraines
Penile Dysfunction
Deterioration in Work Performance
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