In-Depth Health Evaluation from the Perspective of Traditional Chinese Medicine (TCM)

  • FAMILY HEALTH HOLISTIC CENTER

    Quick Hormonal Evaluation

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    For the most accurate evaluation, please complete the form below carefully and thoroughly. Your privacy will be strictly protected (see our Privacy Policy).

    Your Full Name:
    Date of Birth:
    Weight:
    Height:
    Marital Status: single married divorced widowed
    Occupation:
    Email:
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     Check ONLY on those that apply to you

    ED EE
    Hot flashes:
    Night Sweats:
    Vaginal Dryness:
    Foggy Thinking:
    Memory Lapses:
    Incontinence:
    Tearful:
    Depressed:
    Sleep Disturbance:
    Heart palpitations:
    Bone Loss:     		Mood swings:
    Tender breasts:
    Water retention:
    Nervous:
    Irritable:
    Anxious:
    Fibrocystic breasts:
    Uterine fibroids:
    Weight gain in hips:
    Bleeding changes:
    Headaches:
    PD PE
    Hot flashes:
    Night Sweats:
    Vaginal Dryness:
    Foggy Thinking:
    Memory Lapses:
    Incontinence:
    Tearful:
    Depressed:
    Sleep Disturbance:
    Heart palpitations:
    Bone Loss:     		Sleepiness:
    Breast swelling:
    Breast tenderness:
    Decreased libido:
    Mild depression:
    Candida infections:

    AD AE
    Low libido:
    Vaginal Dryness:
    Foggy Thinking:
    Fatigue:
    Memory Lapses:
    Incontinence:
    Aches pains:
    Depressed:
    Sleep Disturbance:
    Decreased muscle mass:
    Bone Loss:     		Excesive facial hair:
    Loss of scalp hair:
    Increased acne
    Oily skin:
    		 
    CD CE
    Fatigue:
    Sugar cravings:
    Allergies:
    Chemical sensitivity:
    Stress:
    Cold body temperature:
    Heart palpitations:
    Aches pains:
    Arthritis:

    		Depressed:
    Sleep Disturbance:
    Decreased muscle mass:
    Bone Loss:
    Fatigue:
    Weight gain in waist:
    Thinning skin:     		 

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