Questionnaire

GROWTH HORMONE DEFECIENCY QUESTIONNAIRE

Candida | Gluten Sensitivity | Food Allergies
Growth Hormone Deficiency | Hypoglycemia

Please assess the following by checking the description that best suits your experience in the following areas.

From the symptoms below, please select the three areas that you are most interested in improving by checking the boxes labeled "Most Interested in Improving".

Full Name:
Email Address:
Confirm Email Address:
Phone Number:

Conditions: Check each symptom according to its severity.
Muscle Tone	Not at All	Slight	Moderate	Significant	Extreme	Most Interested in Improving
1. Reduced Muscle Mass
2. Reduced Muscle Strength
3. Reduced Exercise Performance
4. Increased Body Fat
Lipids
1. Elevated LDL Cholesterol
2. Reduced HDL Cholesterol
Bone
1. Reduced Bone Density
Metabolism
1. Blood Sugar Abnormailities (Hypoglycemia)
2. Reduced Thyroid Function
Hair and Skin
1. Thinning of Skin
2. Wrinkles
3. Decreased Hair and Nail Growth
Mental Health
1. Reduced Energy
2. Reduced Memory and Concentration
3. Depression
4. Emotional Instability
5. Reduced Quality of Sleep
Healing and Immunity
1. Increased Healing Time
2. Decreased Flexibility
3. Increased Susceptibility
Sexual Function
1. Reduced Sex Drive
2. Reduced Sexual Potency
By checking this box, I am giving permission for the results of this questionnaire to be sent to Dr. Patricia Bender and to be contacted by her to discuss them