Symptom Checklist for WOMEN

Use each of the following checklists to determine signs & symptoms of hormone imbalance and help you choose the appropriate profile.

Category 1: Basic Hormone Imbalance

Mark which of the following factors/symptoms are present and/or persist over time.
_____ Hot flashes
_____ Heart palpitations
_____ Heavy menses
_____ Fibrocystic breasts
_____ Low libido/decreased
sexual function

_____ Mood swings (PMS)

_____ Cystic ovaries
_____ Foggy thinking
_____ Irritability
_____ Uterine fibroids

_____ Urinary incontinence

_____ Vaginal dryness
_____ Weight gain
_____ Increased body/facial
hair

_____ Night sweats

_____ Acne
_____ Depressed mood
_____ Headaches
_____ Bone loss

Category 2: Adrenal Hormone Imbalance

Mark which of the following factors/symptoms are present and/or persist over time.
_____ Aches and pains
_____ Sleep disturbances
_____ Chronic health
problems
_____ Low blood sugar

_____ Weight gain

_____ Depression
_____ Evening fatigue
_____ History of steroid usage

_____ Morning fatigue

_____ Anxiety
_____ Allergies
_____ Bone loss

_____ Food cravings

_____ Susceptibility to infections
_____ Autoimmune diseases
_____ Diabetes/prediabetes

Category 3: Thyroid Hormone Imbalance

Mark which of the following factors/symptoms are present and/or persist over time.
_____ Aches and pains
_____ Dry skin
_____ Fatigue
_____ Heart palpitations
_____ Constipation

_____ Anxiety
_____ Cold hands and feet
_____ Foggy thinking
_____ Low libido
_____ Thinning hair

_____ Brittle nails

_____ Headaches
_____ Weight gain
_____ Inability to lose weight
_____ Menstrual irregularities

_____ Depression
_____ Infertility
_____ Feeling cold all the time
_____ Sleep disturbances
_____ Elevated cholesterol

Category 4: Cardiometabolic Risk

Mark which of the following factors/symptoms are present and/or persist over time.
_____ History of smoking
_____ High blood sugar
_____ High blood pressure

_____ Weight gain

_____ Sugar cravings
_____ Fatigue
_____ Low physical activity

If you checked symptoms in all four categories, the suggested test

profiles are:
MINIMUM: Female Blood Profile II (Blood Spot)
PREFERRED: Comprehensive Female Profile I or II (Saliva/Blood Spot)
and CardioMetabolic Profile (Blood Spot)
If you checked symptoms ONLY in Category 1, the suggested test
profiles are:
MINIMUM: Female Blood Profile I (Blood Spot) or Female/Male Saliva
Profile I (Saliva)
PREFERRED: Comprehensive Female Profile I or II (Saliva/Blood Spot)
If you checked symptoms ONLY in Category 2, the suggested test
profiles are:
MINIMUM: Adrenal Stress Profile (Saliva)
PREFERRED: Comprehensive Female Profile I or II (Saliva/Blood Spot)

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Revised 10.07.14

_____ Heart disease or family history of heart disease

_____ Diabetes or family history of diabetes
_____ Waist size greater than 35 inches
_____ Elevated triglycerides

If you checked symptoms ONLY in Category 3, the suggested test

profiles are:
MINIMUM: Essential Thyroid Profile (Blood Spot)
PREFERRED: Comprehensive Female Profile I or II (Saliva/Blood
Spot); OR Comprehensive Elements Thyroid Profile (Blood Spot/
Dried Urine) plus Female/Male Saliva Profile III (Saliva)
If you checked symptoms ONLY in Category 4, the suggested test
profiles are:
MINIMUM: CardioMetabolic Profile (Blood Spot)
PREFERRED: CardioMetabolic Profile (Blood Spot) plus Female/
Male Saliva Profile III (Saliva)

Symptom Checklist for MEN

Use each of the following checklists to determine signs & symptoms of hormone imbalance and help you choose the appropriate profile.

Category 1: Basic Hormone Imbalance

Mark which of the following factors/symptoms are present and/or persist over time.
_____ Burned out feeling
_____ Hot flashes
_____ Weight gain waist
_____ Decreased libido
_____ Decreased erections
_____ Night sweats

_____ Irritable
_____ Erectile dysfunction
_____ Prostate problems
_____ Decreased mental
sharpness

_____ Insomnia
_____ Increased urinary urge
_____ Infertility problems
_____ Oily skin
_____ Apathy

_____ Decreased urine flow

_____ Decreased stamina
_____ Sleep disturbances
_____ Decreased muscle
mass

Category 2: Adrenal Hormone Imbalance

Mark which of the following factors/symptoms are present and/or persist over time.
_____ Aches and pains
_____ Sleep disturbances
_____ Chronic health
problems
_____ Stress

_____ Depression
_____ Lack of motivation
_____ Prostate problems
_____ Evening fatigue

_____ Morning fatigue

_____ Anxiety
_____ Allergies
_____ Weight gain waist
_____ Decreased erections

_____ Bone loss

_____ Low blood sugar
_____ Autoimmune disease
_____ Fibromyalgia
_____ Susceptibility to infections

Category 3: Thyroid Hormone Imbalance

Mark which of the following factors/symptoms are present and/or persist over time.
_____ Low libido
_____ Foggy thinking
_____ Constipation
_____ Elevated cholesterol

_____ Depression
_____ Infertility
_____ Fatigue
_____ Dry skin

_____ Feeling cold

_____ Headaches
_____ Lack of motivation
_____ Heart palpitations

_____ Decreased erections

_____ Sleep disturbances
_____ Inability to lose weight
_____ Brittle nails

Category 4: Cardiometabolic Risk

Mark which of the following factors/symptoms are present and/or persist over time.
_____ History of smoking
_____ High blood sugar
_____ High blood pressure
_____ Low physical activity

_____ Weight gain

_____ Heart disease or family history of heart disease
_____ Sugar cravings
_____ Diabetes or family history of diabetes
_____ Fatigue
_____ Waist size greater than 40 inches
_____ Elevated triglycerides

If you checked symptoms in all four categories, the suggested

test profiles are:
MINIMUM: Male Blood Profile II (Blood Spot)
PREFERRED: Comprehensive Male Profile I or II (Saliva/Blood Spot)
and CardioMetabolic Profile (Blood Spot)
If you checked symptoms ONLY in Category 1, the suggested test
profiles are:
MINIMUM: Male Blood Profile I (Blood Spot) or Female/Male Saliva
Profile I (Saliva)
PREFERRED: Comprehensive Male Profile I or II (Saliva/Blood Spot)
If you checked symptoms ONLY in Category 2, the suggested test
profiles are:
MINIMUM: Adrenal Stress Profile (Saliva)
PREFERRED: Comprehensive Male Profile I or II (Saliva/Blood Spot)

866.600.1636 | info@zrtlab.com | zrtlab.com

Revised 10.07.14

If you checked symptoms ONLY in Category 3, the suggested test

profiles are:
MINIMUM: Essential Thyroid Profile (Blood Spot)
PREFERRED: Comprehensive Male Profile I or II (Saliva/Blood Spot);
OR Female/Male Saliva Profile III plus Comprehensive Elements
Thyroid Profile (Blood Spot/Dried Urine)
If you checked symptoms ONLY in Category 4, the suggested test
profiles are:
MINIMUM: CardioMetabolic Profile (Blood Spot)
PREFERRED: CardioMetabolic Profile (Blood Spot) plus Female/
Male Saliva Profile III (Saliva)