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Hotze Health & Wellness Center
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Hormone, Thyroid & Adrenals for Women
Do you have or experience any of the following?
(Check all that apply)
Does Not Apply
Less than one bowel movement per day?
Restless sleep or difficulty sleeping?
Problems with infertility or miscarriage?
Puffy, pasty or pale skin?
Premenstrual mood swings, fluid retention or weight gain?
Chronic emotion or physical stress?
Poor short term memory?
Tired upon waking, even after a full night's sleep?
Anxiety or panic attacks?
Low pulse rate (less than 70 beats per minute with no exercise)?
Difficulty losing weight?
Muscle aches and joint pain?
Low blood pressure?
Irregular menstrual cycles?
Hot flashes or night sweats?
Feeling as though you might pass out when you rise quickly?
Cold hands and feet?
Recurrent headaches or migraine headaches?
Tingling or numbness in your hands and feet?
Thinning of your eyebrows or eyelashes?
Body temperature below 98.6?
Uterine fibroids, fibocystic breast disease or endometriosis?
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