Hormone Replacement Survey

Which hormones, if any, have you tried supplementing? Which hormones, if any, have you tried supplementing? None Estradiol Estriol DHEA Testosterone Progesterone HGH Thyroid Andrenal

Any hormones tried that are not listed above?

If you have supplemented hormones, whihc forms have you tried? If you have supplemented hormones, whihc forms have you tried? Pellet Cream Injection Troche sublingual (under the tongue) Oral capsule

Other forms tried that are not listed above?

Have you ever been diagnosed with cancer? Have you ever been diagnosed with cancer? Yes No

Check any of the symptoms that fit you (or the person with the concern): Check any of the symptoms that fit you (or the person with the concern): Fatigue or loss of energy Decreased sex drive (libido) Sugar cravings Salt cravings Mood problems Attention problems Sleep problems Frequent colds or flus Excess belly fat High cholesterol Loss of muscle mass Chronic pain Wrinkles Poor memory Sensitive to cold weather Abnormal weight gain all over Dry skin Constipation Difficulty swallowing Brittle nails Hair loss Night sweats Hot flashes Osteopenia or osteoporosis

Any other symptoms not listed above?

Additional Comments or Concerns

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