Men’s Hormone Balance Questionnaire Instructions: please put a 1 if the answer to the question is YESName *Email AddressPhoneDo you or have you experienced in the past six months?PART A - CORTISOLA feeling you're constantly racing from one task to ther next?Feeling wired yet tired?A struggle calming down before bedtime, or a second wind that keeps you up late?Difficulty falling asleep or disrupted sleep?A feeling of anxiety or nervousness - can't stop worrying about things beyond your control?A quickness to feel anger or rage - frequent screaming or yelling?A struggle calming down before bedtime, or a second wind that keeps you up late?Memory lapses or feeling distracted, especially under duress?Sugar cravings (you need "a little something" after each meal, usually of the chocolate variety)?Increased abdominal circumference, greater than 35 inches (the dreaded abdominal fat, or muffin top - not bloating?Skin conditions such as eczema or thin skin (sometimes physiologically and psychologically)?Bone loss (perhaps your doctor uses scarier terms, such as osteopenia or osteoporosis)?High blood pressure or rapid heartbeat?High blood sugar (maybe your clinician has mentioned the words prediabetes or even insulin resistance)?Shakiness between meals, also known as blood sugar instability?Indigestion, ulcers, or GERD (gastroesophageal reflux disease)?More difficulty recovering from physical injury than in the past?Unexplained pink to purple stretch marks on your belly or back?Decreased fertility?TOTALPART B - CORTISOLFatigue or burnout (you use caffeine to bolster your energy, or fall asleep while reading or watching a movie)?Loss of stamina, particularly in the afternoon, from two to five?An atypical addiction to a negative point of view?Crying jags for no particular reason?Decreased problem solving ability?Feeling stressed most of the time (everything seems harder than before, and you have trouble coping)? Decreased stress tolerance?Insomnia or difficulty staying asleep, especially between one and four in the morning?Low blood pressure (not always a good thing, since your blood pressure determines the correct amount of oxygen to send through your body, especially into your brain)?Difficulty fighting infection (you catch every virus you meet particularly respiratory)? Difficulty recovering from illness or surgery or healing wounds?Asthma? Bronchitis? Chronic cough? Allergies?Low or unstable blood sugar?Salt cravings?Excess sweating?Nausea, vomiting, or diarrhea? Or loose stool alternating with constipation?Muscle weakness, especially around the knee? Muscle or joint pain?Hemorrhoids or varicose veins?Your blood seems to pool easily, or your skin bruises easily?A thyroid problem that's been treated, you feel better, and suddenly you feel palpitations or have rapid or irregular heartbeats (a sign of a low cortisol/low thyroid combo?)TOTALPART G - THYROIDHair loss, including the outer third of your eyebrows and/or eyelashes?Dry skin?Dry, strawlike hair that tangles easily?Thin, brittle fingernails?Fluid retention or swollen ankles?An additional few pounds, or 20, that you just can't lose?Muscle or joint aches or poor muscle tone (you became an old lady overnight)?Recurrent headaches?High cholesterol?Bowel movements less often than once a day, or you feel you don't completely evacuate?Tingling in your hands or feet?Cold hands and feet? Cold intolerance? Heat intolerance?A sensitivity to cold (you shiver more easily than others and are always wearing layers)?Slow speech, perhaps with a hoarse or halting voice?A slow heart rate, or bradycardia (fewer than 60 beats per minute, and not because you're an elite athlete)?Lethargy (you feel like you're moving through molasses)?Fatigue, particularly in the morning?Slow brain, slow thoughts? Difficulty concentrating?Sluggish reflexes, diminished reaction time, even a bit of apathy?Low sex drive, and you're not sure why?Depression or moodiness (the world is not as rosy as it used to be)?A prescription for the latest antidepressant but you're still not feeling like yourself?An enlarged thyroid/goiter? Difficulty swallowing? Enlarged tongue?A family history of thyroid problems?TOTALSummaryHigh CortisolLow CortisolLow ThyroidSend Message
