Comprehensive symptom quiz

1

Hi there! How old are you? * This field is required.

2

What's your gender?* This field is required.

Female

Male

3

Are you here for help with fertility?* This field is required.

YESNO

4

Please tell us how often or how severely you experience the following symptoms

5

Not sleeping well (trouble falling or staying asleep)

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

6

Moody or irritable

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

7

Decreased libido and sex drive

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

8

Anxious

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

9

Foggy brain, thinking, or memory

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

10

Dry eyes, hair, or dry skin

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

11

Fatigued, sluggish, or constantly tired

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

12

Thinning head hair

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

13

Palpitations (skipped heart beats or heart pounding)

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

14

Hot flashes or night sweats

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

15

Vaginal dryness and painful sex

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

16

Excess body hair on face, chest, or arms

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

17

Irregular menstrual cycles, heavy or painful periods

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

18

Sexual performance is not as good as it used to be

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

19

Decrease in strength and endurance

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

20

Feeling less social

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

21

Must have caffeine or sugar to get or keep going

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

22

Catch more colds or takes longer to recover from illness

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

23

Feeling overwhelmed

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

24

Feeling tired and anxious (“tired and wired”)

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

25

Losing hair on eye brows or eyelashes

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

26

Thin and brittle fingernails

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

27

Cold hands and feet or feeling colder than everyone else

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

28

Constipation

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

29

Change in bowel movements (constipation or diarrhea)

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

30

Abdominal bloating, uncomfortable gas, indigestion, or heartburn

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

31

Certain foods cause abdominal discomfort or diarrhea

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

32

Have eczema or chronic skin rashes or itching

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

33

Have a diagnosed autoimmune condition

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

34

Unexplained weight gain, or difficulty losing weight

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

35

Have you tried to become pregnant in the last 6 months unsuccessfully?

YESNO

36

Do you have a history of at least one miscarriage?

YESNO

37

Are you currently under the care of a fertility specialist (reproductive endocrinologist) and would like to enhance your chances of getting pregnant?

YESNO

38

Are you hoping to conceive naturally, without medications or procedures?

YESNO

39

Do you have a difficult time going to or staying asleep?

YESNO

40

Are you under a lot of stress?

YESNO

41

Have you noticed your hair thinning?

YESNO

42

Do you have irregular periods?

YESNO

43

Do you have very heavy periods?

YESNO

44

Do you have bothersome stomach symptoms like indigestion, heartburn, bloating, diarrhea, or constipation?

YESNO

45

How frequently do you feel exhausted?

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

46

Have you gained weight around your belly?

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

47

If you found a doctor who can help you with your symptoms, how soon would you want to see them?

As soon as possible

This week

This month

Not sure

48

How many clinicians (doctors, specialists, alternative medicine practitioners, etc.) have you seen for these symptoms?

1-2 different clinicians

3-5 different clinicians

6-9 different clinicians

over 10 different clinicians

49

How familiar are you with holistic and functional medicine?

Not at all

I know a little bit

I've done my research & know enough

I've been using it for a while

I'm an expert

50

What's your first name?* This field is required.

51

What's your email* This field is required.We need your email so we can send you the results and other useful information

example@example.com

52

What state do you live in?* This field is required.Your state will help us show you available clinicians in your area

53

Your Hormone Balance Score (anything over 37 may indicate Hormonal Imbalance)

54

Your Adrenal Health Score (anything over 20 may indicate Adrenal Fatigue)

55

Your Thyroid Function Score (anything over 28 may indicate a Thyroid Disorder)

56

Your Gut Function Score (anything over 24 may indicate a gut imbalance)

57

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58

Please verify that you are human* This field is required.

59

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