Follow up questions Si prefieres responder el cuestionario en Español da click en el botón Español Por favor, activa JavaScript en tu navegador para completar este formulario.Por favor, activa JavaScript en tu navegador para completar este formulario.Name *NombreApellidosDiseñoPhone number *Email *Age (years and months) *Treatment start date *Please enter the approximate date you started your current treatmentPhotos of supplements, hormones, or medication Haz clic o arrastra archivos a esta área para subirlos. Puedes subir hasta 10 archivos. Please provide a photo of the label for your current treatmentList of current treatment *Please include a list of the treatment you are currently following, including instructions for use and approximate time of the day.Type of treatment / follo up *Menopause / PerimenopauseHypothyroidism / Hashimoto'sAdrenal FatigueGastrointestinal HealthOther Which? *Bioidentical Hormone Replacement Therapy (BHRT) Symptom Tracking Form Mark the severity of each symptom on the corresponding date (Not at all, A little, Quite a bit, Extremely) DiseñoHot flushesNot at allA little bitQuite a bitExtremelyFeeling waves of heatNight sweatsNot at allA little bitQuite a bitExtremelyExcessive sweating at nighTrouble sleepingNot at allA little bitQuite a bitExtremelyDifficulty falling or staying asleepMuscle and joint painsNot at allA little bitQuite a bitExtremelyAches in muscles or jointsHeart beating quickly or stronglyNot at allA little bitQuite a bitExtremelyHeart racing or poundingBrain fogNot at allA little bitQuite a bitExtremelyDifficulty concentratingForgetfulness Not at allA little bitQuite a bitExtremelyMemory issuesLess sexual desire (libido)Not at allA little bitQuite a bitExtremelyReduced interest in sexual activityVaginal drynessNot at allA little bitQuite a bitExtremelyDryness causing discomfort during sexLess sexual desire (libido) (copia)Not at allA little bitQuite a bitExtremelyFeelings of nervousness or worryItchy skinNot at allA little bitQuite a bitExtremelySkin irritation or itchinessLess sexual desire (libido) (copia) (copia)Not at allA little bitQuite a bitExtremelyFeelings of nervousness or worryFatigueNot at allA little bitQuite a bitExtremelyGeneral tiredness or lack of energyUrinary issuesNot at allA little bitQuite a bitExtremelyIncontinence or frequent urinationIrregular periodsNot at allA little bitQuite a bitExtremelyUnpredictable menstrual cycles (if applicable)Mood swingsNot at allA little bitQuite a bitExtremelyFeeling unhappy, depressed, or irritableWeight gainNot at allA little bitQuite a bitExtremelyUnexplained weight increaseWeight loss (kg)1 to 2 kg3 to 5 kgMore than 5 kgDon't knowApproximately how much weight have you lost?Weight gain (kg)1 to 2 kg3 to 5 kgMore than 5 kgDon't knowApproximately how much weight have you gained?Thyroid Health Symptom Tracker Form Mark the severity of each symptom on the corresponding date (Not at all, A little, Quite a bit, Extremely) DiseñoFatigueNot at allA little bitQuite a bitExtremelyGeneral tiredness or lack of energyFeeling coldNot at allA little bitQuite a bitExtremelyIntolerance to coldDry skinNot at allA little bitQuite a bitExtremelyDry or itchy skinHair lossNot at allA little bitQuite a bitExtremelyHair or eyebrow thinningConstipationNot at allA little bitQuite a bitExtremelyDifficulty with bowel movementsDepression or mood changesNot at allA little bitQuite a bitExtremelyFeeling sad, irritable, or anxiousBrain fogNot at allA little bitQuite a bitExtremelyDifficulty concentrating or memory issuesWeakness or muscle achesNot at allA little bitQuite a bitExtremelyMuscle weaknessJoint painNot at allA little bitQuite a bitExtremelyPain, stiffness, or swelling in jointsSleep problemsNot at allA little bitQuite a bitExtremelyInsomnia or excessive sleepHeart palpitationsNot at allA little bitQuite a bitExtremelyHeart racing (possible overdose sign)Excessive sweatingNot at allA little bitQuite a bitExtremelySweating or heat intolerance (possible overdose sign)Weight gainNot at allA little bitQuite a bitExtremelyUnexplained weight increaseWeight loss (kg)1 to 2 kg3 to 5 kgMore than 5 kgDon't knowApproximately how much weight have you lost?Weight gain (kg)1 to 2 kg3 to 5 kgMore than 5 kgDon't knowApproximately how much weight have you gained?Adrenal Fatigue Symptom Tracking Form Mark the severity of each symptom on the corresponding date (Not at all, A little, Quite a bit, Extremely) DiseñoChronic fatigueNot at allA little bitQuite a bitExtremelyPersistent tiredness not relieved by sleepDifficulty handling stressNot at allA little bitQuite a bitExtremelyFeeling overwhelmed or stressed easilySleep problemsNot at allA little bitQuite a bitExtremelyDifficulty falling asleep or waking upLow energy in the afternoonNot at allA little bitQuite a bitExtremelyEnergy dip between 3-5 pm or sudden exhaustionLow energy in the afternoonNot at allA little bitQuite a bitExtremelyEnergy dip between 3-5 pm or sudden exhaustionAnxiety or unexplained fearsNot at allA little bitQuite a bitExtremelyNervousness or worry without clear causeDizziness upon standingNot at allA little bitQuite a bitExtremelyLightheadedness or faintness when standing quicklyCravings for salt or sugarNot at allA little bitQuite a bitExtremelyStrong desire for salty or sweet foodsBrain fogNot at allA little bitQuite a bitExtremelyDifficulty concentrating or thinking clearlyMuscle aches or weaknessNot at allA little bitQuite a bitExtremelyWeakness or body achesMood swings or depressionNot at allA little bitQuite a bitExtremelyIrritability, sadness, or hopelessnessFeeling coldNot at allA little bitQuite a bitExtremelyCold intolerance or cold hands/feetWeight changesNot at allA little bitQuite a bitExtremelyUnexplained weight gain or loss, especially abdominalLow libidoNot at allA little bitQuite a bitExtremelyDecreased sexual desireAllergies or sensitivitiesNot at allA little bitQuite a bitExtremelyIncreased allergies or environmental reactionsLow blood pressureNot at allA little bitQuite a bitExtremelySymptoms like fatigue linked to hypotensionGastrointestinal Health Symptom Tracker Form Mark the severity of each symptom on the corresponding date (Not at all, A little, Quite a bit, Extremely) DiseñoUpper abdominal painNot at allA little bitQuite a bitExtremelyPain or discomfort in the upper abdomen (common in gastritis)General abdominal painNot at allA little bitQuite a bitExtremelyPain or cramps in the abdomen (common in IBS, IBD, SIBO)Bloating or distensionNot at allA little bitQuite a bitExtremelyFeeling of a swollen abdomen (common in all)Excessive gasNot at allA little bitQuite a bitExtremelyFlatulence or frequent burping (common in leaky gut, SIBO, IBS)DiarrheaNot at allA little bitQuite a bitExtremelyLoose or frequent bowel movements (common in IBD, SIBO, leaky gut)ConstipationNot at allA little bitQuite a bitExtremelyDifficulty with bowel movements (common in IBS)Nausea or vomitingNot at allA little bitQuite a bitExtremelyFeeling like vomiting or actual vomiting (common in gastritis, SIBO, leaky gut)Feeling of fullnessNot at allA little bitQuite a bitExtremelyFeeling full after eating little (common in SIBO, gastritis)Loss of appetiteNot at allA little bitQuite a bitExtremelyReduced desire to eat (common in SIBO, gastritis, IBD)FatigueNot at allA little bitQuite a bitExtremelyGeneral tiredness (common in leaky gut, IBD, SIBO)Unintentional weight lossNot at allA little bitQuite a bitExtremelyWeight loss without trying (common in IBD, SIBO)Mucus in stoolNot at allA little bitQuite a bitExtremelyMucus in bowel movements (common in IBD, IBS)Blood in stoolNot at allA little bitQuite a bitExtremelyBlood or black stools (common in IBD)Burning sensation in gutNot at allA little bitQuite a bitExtremelyInternal burning feeling (common in leaky gut)Painful indigestionNot at allA little bitQuite a bitExtremelyBurning or discomfort during digestion (common in gastritis, leaky gut)Changes in bowel habitsNot at allA little bitQuite a bitExtremelyAlternating diarrhea and constipation (common in IBS)Aviso Legal *I accept the terms and conditions regarding the submission of personal data. 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