First Health Associates - Alternative In Arlington Heights; IL; USA

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GLAND BALANCE QUESTIONNAIRE FOR MEN

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
Digestive Issues

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

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)

Decreased mental ability or memory

Decreased libido

Loss of muscle mass

Apathetic or less motivation for life

Decreased urine flow

Increased urinary urges

Sleep Disturbances

Feelings of being burnt out

Decreased stamina for exercise

Decreased stamina for sexual activity

Thinning skin, easy to bruise or scratch

Joint stiffness/aches not related to arthritis

Mental Factors (High thyroid production)

Constantly feeling pressured, irritable or anxious
Increased aggressive behavior
Excessive body or facial hair
Foggy thinking or unable to think clearly
Adult acne or oily skin
Increased loss in scalp hair
Elevated cholesterol, especially triglycerides
Increased headaches
High blood pressure
Sleep disturbances (falling asleep/staying asleep)

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.