WOMEN’S INITIAL HORMONE ASSESSMENT TEST

On the form below, please list any of the following symptoms that you may be experiencing:

Specific Signs/Symptoms of Hormonal Imbalance

• mood swings
• irregular menstrual cycle
• low sex drive
• insomnia
• unexplained weight gain or weight loss

Non-Specific Signs/Symptoms of Hormonal Imbalance

• Lower energy level, endurance and physical strength
• Poor memory
• Difficulty with finding words to say
• Poor focus
• Not doing well at work

Having any one of the specific or non-specific symptoms may not mean that you have a Hormonal Imbalance. But if you have a mix of symptoms, for instance, if you start to feel very tired and sad over a period of time and this is a change for you, you may want to check for a Hormonal Imbalance.

Phone: (909) 435-7019

Email: Nick@yucaipapeakperformance.com

Office Hours:

Monday – Friday: 9am-5pm

Saturday: 10am-2pm