Name *

First Name

Last Name

Date

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DD

YYYY

Date of Birth *

MM

DD

YYYY

Estrogen Dominance

Check existing symptoms:

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

Excessive mental chatter

Exaggerated stress response, find it difficult switch off mentally, dwell on things

Crave sugar and chocolate, particularly after meals.

Mood swings are aggravated and follow pattern with menstrual cycle

Headaches or migraines

Poor circulation

Bruise easily or varicose veins

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

Breast tenderness, swelling, or lumpy tissue

Heavy, excessive menstrual bleeding or delayed and / or prolonged menstrual bleeding.

Hypothyroidism

Check existing symptoms:

Fatigue, sluggishness, apathy.

Feeling cold or intolerant to cold

Constipation, slow transit time, dry hard stools.

Dry skin, nails, hair, thin outside third of the eyebrow.

Fluid retention, puffy face, hands, feet

Excessive weight gain, with decreased appetite, bloating and fullness.

Excessive menstrual bleeding, heavier, or more frequent periods.

Sore, swollen, lumpy breasts.

Eyelids drooping covering iris.

Insulin Resistance

Check existing symptoms:

Cysts on ovaries

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

Shaky, cranky and nauseous if you 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, PCOC

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

Resilient on 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

Hypoglycemia

Low blood pressure

Low sex drive

Are you currently taking any prescribed medications? *

If yes, please list below;

Yes

No