DR. ELENA JUTAI N.D. ™ - Hormone Health Analysis
Complete the following questions, I will review your answers and reach out to you with the results.
Email address *
Name: *
Your answer
Phone Number: *
Your answer
Rate the following symptoms based on their severity:
Acne *
None
Severe
Anxiety/Nerousness *
None
Severe
Apathy *
None
Severe
Breast Tenderness *
None
Severe
Brittle Nails *
None
Severe
Burned Out Feeling *
None
Severe
Chemical Sensitivities *
None
Severe
Cold Body Temperature *
None
Severe
Cold Extremities *
None
Severe
Confusion *
None
Severe
Constipation *
None
Severe
Cramping Abdominal *
None
Severe
Cravings for Sweet *
None
Severe
Decreased Concentration *
None
Severe
Decreased Sex Drive *
None
Severe
Decreased Sexual Sensation *
None
Severe
Decreased Stamina *
None
Severe
Deepening of Voice *
None
Severe
Depressed Mood *
None
Severe
Dry Eyes *
None
Severe
Dry Skin/Hair *
None
Severe
Fatigue *
None
Severe
Fibrocystic Breasts *
None
Severe
Fluid Retention Abdomen *
None
Severe
Fluid Retention Extremities *
None
Severe
Foggy Thinking *
None
Severe
Headaches *
None
Severe
Heart Palpitations *
None
Severe
Heavy & Irregular Menses *
None
Severe
Hoarseness *
None
Severe
Hot Flashes *
None
Severe
Hypoglycemia *
None
Severe
Increased Facial and/or Body Hair *
None
Severe
Increased Hair Loss *
None
Severe
Irritability *
None
Severe
Joint Pains *
None
Severe
Low Blood Pressure *
None
Severe
Memory Problems *
None
Severe
Mood Swings *
None
Severe
Muscle Pain *
None
Severe
Night Sweats *
None
Severe
Numbness Hands and Feet *
None
Severe
Painful Intercourse *
None
Severe
Premenstrual Syndrome *
None
Severe
Salt Craving *
None
Severe
Sleep Disturbances *
None
Severe
Swollen Eyes *
None
Severe
Tearfulness *
None
Severe
Thinning Skin *
None
Severe
Tired but Wired *
None
Severe
Urinary Incontinence *
None
Severe
Vaginal Dryness *
None
Severe
Weight Gain: Hips *
None
Severe
Weight Gain: Waist *
None
Severe
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