Stress Test

Please select all the symptoms you are currently experiencing.

Progress:

Difficulty getting up in the morning

Sugar cravings or Salt Cravings

Insomnia/Hard time falling asleep or staying asleep

Gets a “second wind” in the evening, and stay up late

Thoughts are less focused/ Brain Fog/Forgetfulness

Low mood / less enjoyment or happiness with life

Memory is poorer/Forgetfulness

Increased PMS symptoms

Decreased interest in sex/Low Libido

Decreased ability to handle stress

*Name:

*Email:

Phone:

*Would you like more information about correcting these Imbalances? (Y/N)

*May one of our staff members or Doctors contact you to discuss more? (Y/N)

(512) 328-0505

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