Hormonal Balance Assessment for Females

The following assessment gives us an indication of what may be happening with your hormones. For a thorough assessment and natural treatment plan do contact us and we can arrange a face to face or skype or phone consult.

Name

First NameLast Name

Email

Phone

Your age category

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Have you been diagnosed with any of the following? Please select any of the options below which apply to your current health situation

Do you experience any of the following symptoms? Please select any which apply to your right now

Hormonal Balance Test For Females

SYMPTOMS GROUP 1: Please select any which apply

SYMPTOMS GROUP 2: Please select any which apply

SYMPTOMS GROUP 3: Please select any which apply

SYMPTOMS GROUP 4: A combination of symptoms in groups 1 & 3. Please only select if applies.

SYMPTOMS GROUP 5: Please select any which apply

SYMPTOMS GROUP 6: Please select any which apply

*Please note, if you selected 2 or more boxes in any of the six symptom groups your hormones may be out of balance. Please submit your questionnaire at the bottom of this page and a Sheena Hendon Health therapist will contact you soon to inform what type of hormonal imbalance you may have.

Please list below any medication you are currently taking including contraceptives

Please list below any health supplements you are currently taking

Please feel free to provide any other information you feel may assist us in helping you further