Symptoms
Please print out this questionnaire and check any symptoms that apply.
Please fax your questionnaire to us at 912.401.0450 or scan and email it to tabatha@truebalancemd.com and we will contact you to discuss your results.
Male & Female Hormones
- PMS
- Low or decreased libido
- Weight gain
- Hair loss
- Acne
- Facial hair
- Hair loss
- Polycystic ovary syndrome
- Infertility
- Breast or uterine cancer
- Bipolar disorder
- Concentration problems
- Insomnia
- Loss of muscle mass or inability to gain muscle mass
- Fibroids & uterine bleeding
- Fibrocystic breast disease
- Depression & Mood Swings
- Irritability
Adrenal & Stress Hormones
- Fatigue/Insomnia
- Concentration or memoryproblems
- Weight gain
- Truncal obesity
- Bowel inflammation
- Hypertension
- Diabetes
- Autoimmune diseases allergies, sinusitis or respiratory disease
- Attention deficit/Hyperactivity disorder
- Fibromyalgia
- Arthritis, joint & muscle pain
- Depression & other psychiatric disorders
- Hair loss
- Atypcial or hypersensitivity reactions to medications
- Adrenal disease
- Weight gain
Other
- Fibromyalgia
- Migraine
Thyroid Hormones
- Depression & Mood Swings
- Weight gain or loss
- Anxiety
- Irritability
- Constipation
- Diarrhea
- Palpitations
- Fatigue or lethargy
- Hair loss
- Bulging eyes
- Dry skin or hair
- Profuse sweating
- Thyroid disorder
- Cold hands or feet
Gastrointestinal Health
- Colitis
- Constipation
- Diarrhea
- Anemia
- Pet owner
- Yeast candida infections
- Peptic ulcer disease
- Gastric reflux
- Memory problems
- Failure of oral medications to work
- Nutritional deficiency
- Excess gas
- Indigestion or abdominal pain after eating
- Irritable bowel symptoms
- Weight gain
Food Intolerance & Immunity
- Allergies, chronic sinusitis
- Hair loss or respiratory disease
- Frequent infections
- Bowel inflammation
- Weight gain
- Diarrhea or Constipation
- Leaky gut syndrome
- Skin rashes
- Malabsorption
- Attention deficit/hyperactivity disorder
- Celiac’s disease
- Inflammatory or autoimmune diseases
- Failure of oral medications to work
At True Balance MD we use specialized testing to uncover the cause of your symptoms and deliver personalized care with natural measures to correct those causes and deliver you life, restored.
Contact Information
True Balance MD
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