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* 1. Are you male or female?

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* 2. Which category below includes your age?

If you are a female, please go to Question 3

If you are male, please go to Question 4

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* 3. FEMALE#:
Do you suffer from any of the following conditions (please select all that apply)

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* 4. MALE#:
Do you suffer from any of the following conditions (Please select all that apply.)

# As you will see from above check boxes, they have all been numbered, dividing them in to different groups. (Female 1,2,3,4,5 and 6 and Male 1 & 2)
If you have ticked 2 or more boxes in a specific group, you may have a hormonal imbalance.

Scroll to the bottom to find out the answers.

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* 5. Please tick the boxes below If you have checked 2 or more boxes from above or if this does not apply to you

F1 - F6 (Women)
M1 - M2 (Men)



Progesterone deficiency: This is the most common hormone imbalance among women of all ages. You may need to change your diet, get off of synthetic hormones (including birth control pills), and you may need to use some progesterone cream and try saliva or blood testing for progesterone and estradiol.

Estrogen deficiency: This hormone imbalance is most common in menopausal women; especially if you are petite and/or slim. You may need to make some special changes to your diet and try saliva or blood testing for estradiol.

Excess estrogen: In women, this is most often solved by getting off of the conventional synthetic hormones most often prescribed by doctors for menopausal women. Once you're on a natural hormone regimen, you may want to get a comprehensive saliva or blood test.

Estrogen dominance: This is caused when you don't have enough progesterone to balance the effects of estrogen. Thus, you can have low estrogen but if you have even lower progesterone, you can have symptoms of estrogen dominance. Many women between the ages of 40 and 50 suffer from estrogen dominance. Try saliva or blood testing or just test for progesterone and estradiol.

Excess androgens (male hormones): This is most often caused by too much sugar and simple carbohydrates in the diet and is often found in women who have polycystic ovary syndrome (PCOS). Try saliva or blood hormone testing for progesterone, estradiol and testosterone.

Cortisol deficiency: This is caused by tired adrenals, which is usually caused by chronic stress. If you're trying to juggle a job and a family, chances are good you have tired adrenals. Try saliva or blood hormone testing for the Adrenal Function or one of the individual Cortisol tests.

You can also read about hormones in books by Dr. John R. Lee (you can find books from



Testosterone deficiency: This is most common in men over the age of fifty, and can be remedied with special nutritional supplements; increased muscle-building exercise; and supplemental hormones including (natural) testosterone, progesterone, and DHEA. You can find details in Dr. Lee's booklet, Hormone Balance For Men. It is also recommended that you get a saliva hormone test to find out which hormone(s) would be best for you. A basic set of baseline tests for men would include testosterone, DHEA, estrogen and progesterone through a saliva test. It may also be helpful to measure morning and evening cortisol by saliva test, and SHBG (Sex Hormone Binding Globulin) by blood spot test.

Excess estrogen: In men, excess estrogen can be balanced with one of the male hormones and changes in diet and lifestyle. You can read about this in detail in Dr. Lee's booklet, 'Hormone Balance For Men'. It is recommended that you get a saliva hormone test to pinpoint your hormone balance more exactly.

More books by Dr. John R. Lee can be obtained from Amazon.

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* 6. Do you have any other unwanted symptoms that are NOT listed on this form? If so, please add them below.

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* 7. Thank you for taking the time to complete this short survey.

PLEASE NOTE: The above is just a guideline and for market research purposes only. If you are concerned about your hormones, please contact your doctor.

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