Last Name
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First Name
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Email
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Perimenopause Checklist
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Decreased enjoyment in daily activities
Increased social isolation and changes in wardrobe
Abdominal weight gain and emotional instability
Dissatisfaction with exercise and general feelings of blah
Sleep disturbance and night sweats
Hot flashes and mood swings
Forgetfulness and cognitive changes
Preference for comfort foods over sex
Consideration of antidepressants or hormonal treatments
None of the above - put 0 in score
Perimenopause Total Score
Low Testosterone Checklist
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Thinning body hair, especially underarms and pubic area
Signs of premature hair loss, particularly at the temples
Decreased interest in physical activity and sports
Experience of intense emotional stress or trauma
Participation in long-distance running or endurance exercises
Gradual decline in sex drive since twenties
Decreased clitoral sensitivity and painful intercourse
Increased passivity and risk aversion
Heightened sensitivity to stress and increased fragility
Muscle loss, cellulite, and varicose veins
None of the above, put 0 in the score
Low Test Total Score
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Low Thyroid Checklist
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Hair loss, including eyebrows and eyelashes
Dry skin and hair
Brittle fingernails
Fluid retention or weight gain
High cholesterol
Irregular bowel movements
Recurrent headaches
Decreased sweating
Muscle or joint aches
Cold intolerance
Slow speech and hoarse voice
Bradycardia (slow heart rate)
Lethargy and fatigue
Slow cognition and concentration
Low sex drive
Depression and moodiness
Menstrual problems or infertility
Enlarged thyroid or goiter
Difficulty swallowing
Family history of thyroid issues
None of the above, put 0 in the score
Low Thyroid Score
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Insulin Checklist
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Do you experience frequent hunger, especially shortly after eating
Have you noticed unexplained weight changes, particularly weight gain about the abdomen?
Do you often feel fatigued or experience low energy levels, especially after meals?
Have you experienced increased thirst or frequent urination?
Do you have a family history of diabetes or insulin resistance?
Have you been diagnosed with gestational diabetes during pregnancy?
Do you have polycystic ovary syndrome (PCOS)?
Have you noticed changes in your skin, such as darkened patches or skin tags?
Do you experience blurred vision or other eye-related issues?
Have you been diagnosed with metabolic syndrome or pre-diabetes?
None of the above, put 0 in the score
Insulin Score
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Cortisol Checklist
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Feeling wired by tired
Difficulty falling asleep or disrupted sleep
Increased anxiety or quickness to anger
Memory lapses or distraction
Sugar cravings and waist circumference increase
Skin conditions and bone loss
High blood pressure or rapid heartbeat
Shakiness between meals
Fatigue and loss of stamina
None of the above, put 0 in the score
Cortisol Score
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Menopause Checklist-only if you haven't had a menstrual cycle for a year +
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Poor memory or cognitive issues
Emotional fragility, depression, or anxiety
Wrinkles and skin changes
Night sweats or hot flashes
Trouble sleeping
Bladder issues
Loss of breast volume
Achy joints and decreased interest in exercise
Vaginal dryness and decreased libido
Painful sex
None of the above, put 0 in the score
Menopause Score
Menstrual Cycle Checklist- skip if you are in menopause
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Agitation or PMS
Cyclical headaches (especially menstrual or hormonal migraines)
Painful and/or swollen breasts
Irregular menstrual cycles or increased frequency with age
Heavy or painful periods
Bloating or fluid retention
Easily disrupted sleep
Itchy or restless legs, particularly at night
Increased clumsiness or poor coordination
infertility or subfertiility
Miscarriage in first trimester
None of the above, put 0 in the score
Menstrual Score
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Please check your email for your quiz results from
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