GLAND BALANCE QUESTIONNAIRE FOR WOMEN

Symptoms are a major factor in determining a hormonal or thyroid imbalance and are the keys to developing an effective plan of care to create balance.

If you experience more than 3 symptoms in any category, or more than 10 total, ask one of our practitioners about our comprehensive thyroid and hormone test to investigate clinical and sub-clinical hormone imbalances that might be the answer that you have been looking for.
Click Here for a .doc version of the questionnaire

Please check any of the following symptoms that you are currently or have previously experienced:

Physical Symptoms (Low Thyroid Production)

Weight Loss Resistance
Cold feet or hands 
Sluggish reaction time or reflexes
Fatigue (energy drops out during day)
Poor Mood or Depression
Problems with skin (adult acne/eczema)
Hair loss/thinning
Brittle/cracked nails
Throat, neck, or tongue swelling
Little tolerance for exercise
No strength increase from exercise
High Cholesterol
Constipation

Physical Symptoms (High Thyroid Production)

Bulging eyes or “staring gaze”
Fast heart rate
Tremors in hands
Swelling/tenderness in front of neck
Panic Attacks
Feeling hot/sweating
High Energy
Unintentional Weight Loss
Loose stools
Light Periods/missing periods
Often feel like “I’ve had too much coffee"
Digestive Issues

Emotional Factors (Low Thyroid Production)

Frequently “fly off the handle”
Startled easily
Poor recovery time from illness
Dizziness upon standing
Low stamina for stressful situations
Sweating when nervous
“Seems like I’m always stressed out”
Very sensitive to chemicals or allergies
Low tolerance for alcohol or caffeine
Hard to get going in the morning
Afternoon Fatigue
Salt Cravings
Fatigued all day but wired at bedtime

Emotional Factors (High Thyroid Production)

Thinking gets clouded when I’m rushed
Swelling in fingers, ankles, limbs, or face
Heart Palpitations
High Blood Pressure
Easy bruising or oily skin
Insomnia
High Triglycerides
Sugar Cravings
Muscle weakness
Restless legs at night
Generalized tension
Constant low grade headache

Mental Factors (Low thyroid production)

Brain Fog
Inability to resolve dilemmas
Hot flashes
Night Sweats
Feeling tearful even at slight provocation
First few days of period are worst days of month
Sleep Disturbances
Memory Lapses
Frequent Headaches (temples/entire head)
Vaginal Dryness
Incontinence (inability to hold urine without leakage)
Irregular Periods (light/heavy)

Mental Factors (High thyroid production)

Exceptionally fine, smooth skin
Heavy bleeding (menstruation)
Tender breasts
PMS time is very difficult
Lumps or cysts in breasts
Cystic Ovaries
Abdominal Weight Gain
High Triglycerides
Anxiousness, nervousness, irritability
Swollen ankles, legs, fingers, or face

First Health Associates
Phone:  (847) 593-3330
2010 S. Arlington Heights Rd 
Arlington Heights, IL  60005

Form adapted from Thyroid Power by Richard Shames, M.D.

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