Name *

First Name

Last Name

Date

MM

DD

YYYY

Date of Birth *

MM

DD

YYYY

Estrogen Dominance/Low Testosterone

Check existing symptoms:

Holding Fat on buttocks, thighs, hips, back of the arms, love handles, lower abdomen, lower back, chest.

Hair Loss/balding

Excessive mental chatter

Exaggerated stress response and harder to switch off so can dwell on things

Crave sugar and chocolate, particularly after meals.

Mood swings are aggravated

Headaches or migraines

Poor circulation

Bruise easily and varicose veins

Bloated and fluid retention, especially in abdomen, hips and thigh

Swelling, or lumpy fat tissue

Insulin Resistance

Check existing symptoms:

Poor blood sugar control - Hyperglycaemia (high blood sugar) or reactive hypoglycaemia (low blood sugar).

Shaky, cranky and nauseous if miss a meal.

Acne, cysts, infected hair follicles.

Sugar cravings

Fatigue and sweet cravings after meals

Weight gain, inability to lose fat

Poor muscle growth

Excessive fat to muscle ratio

Diagnosed with type 2 diabetes

Adrenal Fatigue

Check existing symptoms:

Heightened anxiety and stress

Body aches/poor recovery after exertion

Constant fatigue/tiredness

Allergies – sinus, running nose, headaches, itchy eyes

Intolerance's/infections/infestations

Skin rashes – eczema, hives, rosacea,

Acne/breakouts

Wide awake at night and tired upon waking in the morning

Inflammation and pain

Unexpected weight loss/weight gain

Resistance to stimulants

Poor digestion – IBS/Diarrhoea/Constipation

Poor sleep quality (urinating during the night)

Toxic exposure (in the workplace/at home)

Poor mental clarity/memory

Fat accumulation around the tummy

Fluid retention

Inability to gain lean muscle mass easily/muscle weakness

Craving salty/fatty/sugary foods

Hypoglycaemia

Low blood pressure

Low sex drive

Are you currently taking and prescriptions medications? *

If Yes, please elaborate below;

Yes

No