Doctor Maiquez, anti-aging, board certified, Age Management Physician Miami

Please Click again on the Yellow Bottom of Hormone Imbalance Questionnaire To get the Document Version Please Fill it out, Print it and Bring it to your next Appointment HORMONE QUESTIONNAIRE
ADONIS MAIQUEZ, MD
Name: ____________________________________	Date: ____/____/_____
MENTAL, EMOTIONAL and PHYSICAL COMPLAINTS (check only if positive)

Growth Hormone	YES
Do you often feel unwell?	____
Do you feel lack of inner peace?	____
Do you feel chronically anxious?	____
Do you have a tendency to be depressed?	____
Do you feel a lack of self control?	____
Do you have outbursts of panic/anxiety?	____
Do you have tendency to social isolation?	____
Do you get easily exhausted?	____
Difficulty recovering when going late to bed?	____
Feeling of collapsing?	____
Feeling of rapidly aging?	____
Light sleep?	____
Excessive need for sleep-9 hours or more?	____
Melatonin
Is your sleep superficial, agitated?	____
Easily waking up during the night?	____
Difficulties to fall asleep and fall back asleep?	____
Poor dreaming?	____
Feeling of agitation?	____
Restless leg syndrome at night?	____
Tense muscles at night?	____
Hypothyroidism
Do you often feel slow?	____
Easily distracted?	____
Poor concentration, poor attention?	____
Poor memory?	____
Poor school performance?	____
Are you prone to ear, nose and throat infections?	____
Prone to weight gain, difficulty losing weight?	____
Are you overweight or obese?	____
Are you swollen all over?	____
Do you complain of morning fatigue?	____
Lethargy, apathy?	____
Feel best in the evening and when physically or mentally active?	____
Tiredness when taking a rest?	____
Do you have intolerance to cold and heat?	____
Inability to sweat in a hot climate?	____
Easily shivers, need to wear extra clothes in all seasons?	____
Poor circulation (white fingers in winter)?	____
Do you have dry hair?	____
Slow growing hair?	____
Diffuse hair loss?	____
Do you suffer from diffuse headaches?	____
Migraine headaches?	____
Do you have tinnitus (ringing in ears)?	____
Dry skin?	____
Brittle, slow growing nails?	____
Do you suffer from bloated abdomen?	____
Dyspepsia/slow digestion/constipation?	____
Muscle and joint stiffness or pain upon waking?	____
Feet and leg cramps at night?	____
Carpal tunnel syndrome/low back pain?	____
Pregnenolone
Do you have poor color vision?	____
Fatigue?	____
Dry skin? (poor sebum production)	____
DHEA (Dehydroepiandrosterone) & Androstenedione
Men Low sexual desire?	____
Erectile dysfunction?	____
Women Low sexual desire?	____
Low sexual satisfaction?	____
Cortisol
Do you have poor resistance to stress, or difficulty functioning in stressful situations?	____
Excessive sensitivity to human suffering?	____
Excessive compassion for the pain of others?	____
Do you often feel irritable?	____
Frequent negativism?	____
Feeling of being a victim?	____
Are you an accusatory, quarrelsome person?	____
Outbursts of anger, anxiety, panic?	____
Easy screaming or yelling?	____
Do you use sharp verbal retorts, strong words?	____
Do you feel intense hunger attacks?	____
Sweet cravings?	____
Frequent nausea?	____
Lack of appetite?	____
Salty food cravings?	____
Arthritis?	____
Do you have a predisposition to inflammatory diseases?	____
Acute allergies:conjunctivitis, otitis, rhinitis, asthma, food allergies?	____
Chronic inflammatory diseases: rheumatoid arthritis, lupus?	____
Intolerance to medications?	____
Aldosterone
When standing up or sitting (from lying down):
Do you feel drowsiness?	____
Are you easily distracted, absent-minded?	____
Daydreaming?	____
Do you have difficulty focusing on tasks?	____
Feel better when lying flat on a bed?	____
Difficulty focusing objects (vision) when standing?	____
Salt and salty food cravings?	____
Thirsty, drinking water/liquids all the time?	____
Polyuria (frequent urination)?	____
WOMEN
Estrogen
Do you feel persistently fatigued?	____
Persistent depression?	____
Hot flushes with excessive night sweats?	____
Breast ptosis (droopy breasts)?	____
Menstrual cycle irregularities, shorter/longer?	____
Scanty or no periods?	____
Vaginal dryness?	____
Vaginal itching?	____
Recurrent cystitis (bladder infections)?	____
Urinary stress incontinence?	____
Prolapsed urinary bladder?	____
Progesterone deficiency (or estrogen excess)
Do you feel muscle and nervous tension?	____
Irritable, aggressive?	____
Anxious, angry?	____
Premenstrual breast tension/tenderness?	____
Premenstrual abdominal bloating?	____
Excessive menstruation?	____
Testosterone
Do you feel lack of mental firmness?	____
Feel undecided, hesitating?	____
Loss of self-confidence?	____
Lack of authority, submissiveness?	____
Do you have chronic depression?	____
Excessive anxiety, fears?	____
Excessive emotions, sensitivity to difficulties?	____
Hypochondriac or often sick?	____
Permanent fatigue that increases with activity?	____
Do you feel tired easily/lack of energy?	____
Lack of interest in sports, lack of endurance?	____
Reduced muscle strength, volume? Muscle pain?	____
Urinary incontinence?	____
Decreased/absent libido/sensitivity clitoris, nipples?	____
Decreased/absent orgasm?	____
MEN
Testosterone
Do you have lack of mental firmness?	____
Indecisive, hesitating?	____
Loss of self-confidence?	____
Lack of authority, submissiveness?	____
Do you suffer from chronic depression?	____
Excessive anxiety, fears?	____
Excessive emotions, unnecessary worry?	____
Do you suffer from hot flashes?	____
Sweating spells (head, upper chest)?	____
Persistent fatigue that increases with physical activity?	____
Fatigability and lassitude (laziness)?	____
Lack or endurance/interest in exercise?	____
Decreased muscle mass/strength, muscle pain?	____
Prostate infections?	____
Urination problems: flow problems, painful urination?	____
Frequent night-time urination?	____
Decreased/absence of:
Sex drive?	____
Erection volume, firmness, persistence or frequency?	____
Ejaculation volume?	____
Progesterone
Do you have lack of inner peace, anxiety?	____
Do you have superficial nervous sleep?	____
Reduced urine flow?	____
Need for more time to urinate (dysuria)?	____
Note: Please click again on the Yellow Bottom Hormone Imbalance Questionnaire to have the document version of this Questionnaire. Please Fill it out, Print it and Bring to your Appointment. ----- (Modified from Thierry Hertoghe, M.D.)

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(305) 644-2212

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351 NW 42nd Ave.
Lejeune Road,Suite 315
Miami, Florida 33126
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