Current Condition - Women (Check all that apply) Sleep: Insomnia Nightmares Awaken at Night @ am Appetite: Good Fair Poor     Urination: Frequency: x/24hrs Pain Burning     Digestion: Indigestion Belching Bloating Gas Cramps Other Bowels: Frequency: x/day Constipation Diarrhea Bleeding Menstruation: (Complete all that apply) Age Began: Cycle (days between periods): Duration: (days) Last Period Began On: Vaginal discharges? Clots? Cramps before flow? Cramps during flow? Cramps after flow? Age at Menopause: Birth Control: Which? At what age: Year of last Pap test: Year of last Mammogram: Pregnancies: #of births: #of miscarriages: #of abortions: Did you nurse: For how many months: Drugs (marijuana, cocaine, etc.) If yes, when? Smoking: Current smoker x/day Former smoker Total years: Year stopped: Non smoker Physical Activity: (exercise, sports):

Category 1: Basic Hormone Imbalance Note which of the following symptoms are troublesome and/or persist over time. Hot flashes Mood swings (PMS) Urinary Incontinence Night sweats Heart palpitations Cystics ovaries Vaginal dryness Acne Heavy menses Foggy thinking Weight gain Depressed mood Fibrocystic breasts Irritability Increased body/facial hair Headaches Thinning skin Uterine fibroids     Bone loss   Category 2: Adrenal Hormone Imbalance Note which of the following symptoms are troublesome and/or persist over time. Aches and pains Elevated triglycerides Morning fatigue Bone loss Sleep disturbances Depression Anxiety Blood sugar imbalance Infertility Nervousness Allergic conditions Autoimmune illness Chronic Illness Evening fatigue Susceptibility to infections       Category 3: Thyroid Hormone Imbalance Note which of the following symptoms are troublesome and/or persist over time. Aches and pains Anxiety Brittle nails Depression Dry skin Cold hands and feet Headaches Infertility Fatigue Foggy thinking Weight gain Feeling cold all the time Heart palpitations Low libido Inability to lose weight Sleep disturbances Constipation Thinning hair Menstrual irregularities Elevated cholesterol