Growth Hormone Deficiency Checklist

This checklist is designed to assist Brainwaves in determining whether you are growth hormone deficient.  This form alone cannot make a diagnosis of growth hormone deficiency.  A diagnosis can only be made by a qualified professional.  Once your checklist has been received, your results and gift certificate for 20% off products or services will be emailed to you.  Please contact our office at 713.796.0022 if you have any questions regarding growth hormone or other hormonal deficiencies.

  1. Please provide the following contact information:

    Name
    Street Address
    Address (cont.)
    City
    State/Province
    Zip/Postal Code
    Country
    Cell Phone
    Home Phone
    E-mail

  2. Please identify and describe yourself:

    Age
    Sex Male Female
    Height
    Weight

     

  3. Choose one of the following options:
    I feel fatigued all of the time.
    I feel fatigued some of the time.
    I do not feel fatigued.

  4. Select any of the following options that apply:
    I have been in a car accident.
    I have been hit in the head.
    I have fallen and hit my head.

  5. Choose one of the following options:
    I do not experience joint pain or stiffness.
    I frequently experience joint pain or stiffness.
    I experience joint pain or stiffness only after exercise.

  6. Choose one of the following options:
    I have been diagnosed with osteoporosis.
    I have not been diagnosed with osteoporosis.

  7. Choose one of the following options:
    I have had multiple injuries requiring surgery.
    I have never had surgery.

  8. Choose one of the following options:
    I am able to lose weight around my middle easily.
    Even with daily exercise, I cannot lose weight around my middle.
    If I try, I can lose weight.

  9. Choose one of the following options:
    I have never been diagnosed with thyroid problems.
    Thyroid problems run in my family.
    I have been diagnosed with thyroid problems.

  10. Select any of the following options that apply:
    I fall asleep easily and sleep through the night.
    I wake up throughout the night.
    I sleep through the night but do not feel rested upon waking.

  11. Choose one of the following options:
    I am able to build and maintain my muscle with weight lifting.
    I am unable to build and maintain muscle.

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Revised: 10/04/07