Review of Symptoms – Your Labwork – Natural thyroid and hormone treatment

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Review of Symptoms – Your Labwork

Name*
First Last
Email*
Phone*
Do you have any of the following symptoms?
Please select all that apply in each category
General
- Unexplained Weight Loss
- Night Sweats
- Fatigue/Lethargy
- Abnormal Appetite
- Fever
- Itch/Rash
- Recent Trauma
- Lumps/Bumps/Masses
- Unexplained Falls
- Sleep Disturbance
Eyes
- Changes in Vision
- Headache
- Eye Pain
- Double Vision
- Floaters
Ears/Nose/ Mouth
- Runny Nose
- Nose Bleeds
- Sinus Pain
- Stuffy Ears
- Ear Pain
- Ringing in Ears
- Bleeding Gums
- Toothache
- Sore Throat
- Pain with Swallowing
Heart
- Chest Pain
- Shortness of Breath
- Exercise Intolerance
- Fainting
- Leg swelling
- Palpitations
Lungs
- Cough
- Sputum
- Wheezing
- Coughing up Blood
- Shortness of Breath
Intestines
- Abdominal Pain
- Unexpected Weight Loss
- Difficulty Swallowing
- Indigestion
- Bloating
- Cramping
- Loss of Appetite
- Nausea and Vomiting
- Diarrhea
- Constipation
- Rectal Bleeding
Urinary
- Difficulty Urinating
- Frequent Bladder Infections
- Visible Blood in Urine
- Frequent Nighttime Urination
GYN
- Early Menopause
- Hot Flashes
- Night Sweats
- Abnormal Vaginal Discharge
- Vaginal Pain
- Heavy Menstrual Cycles
- Unusual Change in Cycles
Musculoskeletal
- Pain
- Stiffness
- Misalignment
- Joint Swelling
- Arthritis
- Muscle weakness
- Decreased Range of Motion
Breast
- Breast pain
- Breast soreness
- Abnormal lumps
- Abnormal discharge
Neurologic
- Changes in hearing
- Changes in taste
- Sensation of pins and needles
- Poor memory
- Numbness
- Difficulty with speech
Hormonal
- Hair loss
- Dry skin
- Abnormal weight gain
- Frequent urination
- Dizziness
- Unexplained high blood pressure
- Patchy darkening of skin
- Unexplained vaginal bleeding
Blood
- Anemia
- Easy bruising
- Red dots on skin
- Easy bleeding
- History of blood transfusion
- Refused for blood donation
Allergic
- Insect allergy
- Known Airborne allergy
- Known food allergy
- Hay fever

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