Embracing Health

Saliva Hormone Test Questionnaire

Step 1: Personal Details

Full Name Date of Birth
Email Gender
Address Height
Weight
How did you find out about this testing service?
Consultation - Preferred Day Preferred Time Contact # for consultation
Medications including Oral Contraceptive Pill, HRT or Bio-identical Hormones
Supplements
Operations had, organs removed
Diagnosed with any specific disease or disorder

Step 2: Tick YES what's applicable to you. Not sure or Not applicable? Leave as is..
Currently menstruation  Y N Muscle/Joint pain  Y N
Menopausal  Y N Breakthrough bleeding  Y N
Hot flushes/Sweats  Y N Asthma/Allergies  Y N
Apathy/Brain Fog  Y N Muscle spams  Y N
Depression  Y N Mood swings  Y N
Fatigue  Y N Anxiety  Y N
Low libido  Y N
Vaginal dryness  Y N Low motivation  Y N
Insomnia  Y N "Out of control" feelings  Y N
Memory loss  Y N Anaemia, low iron  Y N
Urinary incontinence  Y N Muscle weakness  Y N
Urinary frequency  Y N Poor attention/focus  Y N
Poor skin tone/wrinkles  Y N Low blood pressure  Y N
Headaches  Y N Trouble keeping weight on  Y N
Panic attacks  Y N
Cold hands/feet  Y N Salt cravings  Y N
Weight gain - all over  Y N Lowerback/kidney pain  Y N
Weight gain - belly/middle  Y N Dark rings under eyes  Y N
Weight difficult to lose  Y N Erectile dysfunction  Y N
Hair thinning/falling out  Y N Incomplete urination  Y N
Sensitive to temperature  Y N Prostate enlargement  Y N
Puffy face/eyelids  Y N Step 3 : Family History of:
Dry coarse skin  Y N Breast cancer
Prostate Cancer
Acne  Y N Other Cancer
Mail hair growth (women)  Y N Cardiovascular Disease
Sugar cravings  Y N Type 2 diabetes
Bloating after meal  Y N Osteoporosis
High blood pressure  Y N Thyroid disorders
Contact Us | Terms of Use | Privacy Policy | Purchase Agreement
Copyright © 2009-2010 Embracing Health Pty Ltd. All Rights Reserved.