Female Questionnaire
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LABORATORY TEST RESULTS

If you have any that are still relevant to your present condition, you may enter them below.

NOTE: Measurements are in 'conventional' (U.S.)  units, with Standard International (SI) units in [brackets] where different.
 

NOTE ALSO: Lab test results can also be submitted as:

- Word processor files (.doc, .rtf)
- Adobe Acrobat files (.pdf)
- Scanned images (.jpg, .gif, .png, etc.)
- Plain text.

Simply request instructions after completing the questionnaire.

LABORATORY VALUES – BLOOD AND OTHER CELLS

Please note any known results, even if all you know is that they were "normal".  Skip all questions that you are uncertain of.  Further notes can be added against any question.

Q939

Erythrocyte Sedimentation Rate (ESR) or Red Blood Cell Sedimentation Rate. Unit: mm/h
  • Don't know
  • 0 to 15 (normal)
  • 16 to 25
  • 26 to 40
  • Over 40

Q940

Hemoglobin (Hb, HGB). Unit: g/dL [g/L] or [mmol/L]
  • Don't know
  • Under 9.0 [90] [5.7]
  • 9.0-11.9 [90-119] [5.7-7.3]
  • 12-16.0 [120-160] [7.4-9.9] (normal)
  • Over 16.0 [160] [9.9]

Q941

Hematocrit (HCT). Unit: Percent [fraction]
  • Don't know
  • Under 25% [0.25]
  • 25 to 35% [0.25-0.35]
  • 36 to 46% [0.36-0.46] (normal)
  • Over 46% [0.46]

Q942

Mean Cell or Corpuscular Hemoglobin (MCH). Unit: pg/cell
  • Don't know
  • Under 26
  • 26 to 27
  • 28 to 32 (normal)
  • Over 32

Q943

Mean Corpuscular Volume (MCV). Unit: Femtoliters; fL
  • Don't know
  • Below 75
  • 75 to 81
  • 82 to 98 (normal)
  • Over 98

Q944

Platelet count (PLT). Unit: x10^3/uL or x10^9/L
  • Don't know
  • Under 100
  • 100 to 149
  • 150 to 450 (normal)
  • Over 450

Q945

Red Blood Cell count (RBC). Unit: x10^6/uL or x10^12/L. NOTE: If your results show large numbers, divide by 1000 (i.e. 3900 becomes 3.9).
  • Don't know
  • Under 3.2 (very low)
  • 3.2 to 4.2 (low)
  • 4.3 to 5.4 (normal)
  • Over 5.4 (high)

Q946

T-helper (CD4) cells (an immune cell type, unrelated to the thyroid)
  • Don't know
  • Under 150
  • 150 to 349
  • 350 to 500
  • Over 500 (normal)

Q947

Leukocytes (White Blood Cell count - WBC). Unit: x10^3/uL or x10^9/L. NOTE: If your results show large numbers, divide by 1000 (i.e. 3900 becomes 3.9).
  • Don't know
  • Under 3.5
  • 3.5 to 4.8
  • 4.9 to 10.0 (normal)
  • Over 10.0

Q948

White Blood Cells - Neutrophil Percentage [fraction]. If you only have the absolute neutrophil count (ANC), divide white blood cell count (WBC) by ANC, and multiply by 100.
  • Don't know
  • Under 40% [0.40] (low)
  • 40 to 70% [0.40-0.70] (normal)
  • 71 to 80% [0.71-0.80] (elevated)
  • Over 80% [0.80] (high)

Q949

White Blood Cells - Lymphocyte Percentage [fraction]
  • Don't know
  • Under 20% [0.20] (low)
  • 20 to 45% [0.20-0.45] (normal)
  • 46 to 55% [0.46-0.55] (elevated)
  • Over 55% [0.55] (high)

Q950

White Blood Count - Monocyte Percentage [fraction]
  • Don't know
  • Under 4% [0.04] (low)
  • 4 to 10% [0.04-0.10] (normal)
  • 11 to 15% [0.11-0.15] (elevated)
  • Over 15% [0.15] (high)

Q951

White blood Cells - Eosinophil Percentage [fraction]
  • Don't know
  • 0 to 6% [0.00-0.06] (normal)
  • 7 to 10% [0.07-0.10] (slightly elevated)
  • 11-20% [0.11-0.20] (elevated)
  • Over 20% [0.20] (high)

Q952

White Blood Cells - Basophil Percentage [fraction]
  • Don't know
  • 0 to 2% [0.00-0.02] (normal)
  • 3 to 5% [0.03-0.05] (somewhat elevated)
  • 6 to 10% [0.06-0.10] (elevated)
  • Over 10% [0.10] (high)

LABORATORY VALUES – CHEMISTRIES

Please note any known results, even if all you know is that they were "normal".  Skip all questions that you are uncertain of.

Q953

Albumin. Unit: g/dL [g/L]
  • Don't know
  • Under 3.8 [38] (very low)
  • 3.8 to 4.2 [38-42] (low)
  • 4.3 to 5.0 [43-50] (normal)
  • Over 5.0 [50] (high)

Q954

Antinuclear Antibodies (ANA). Unit: Titre
  • Don't know
  • Under 1:40 (normal)
  • 1:40 to 1:100
  • 1:101 to 1:500
  • Over 1:500

Q955

Bilirubin, total. Unit: mg/dL [umol/L]
  • Don't know
  • 0.0 to 1.3 [0-22] (normal)
  • Recently elevated
  • Chronically elevated

Q956

Bilirubin, direct. Unit: mg/dL [umol/L]
  • Don't know
  • 0.0 to 0.3 [0-5] (normal)
  • Recently elevated
  • Chronically elevated

Q957

Bilirubin, indirect. Unit: mg/dL [umol/L]
  • Don't know
  • 0.1 to 1.0 [2-17] (normal)
  • Recently elevated
  • Chronically elevated

Q958

Cholesterol, Total. What is your total cholesterol level? Unit: mg/dL [mmol/L]
  • Don't know
  • Under 150 [3.89]
  • 150 to 200 [3.89-5.19] (normal)
  • 201 to 240 [5.20-6.22] (mildly elevated)
  • Over 240 [6.22] (elevated)

Q959

Cholesterol, HDL. What is your fasting HDL cholesterol level? Unit: mg/dL [mmol/L]
  • Don't know
  • Under 21 [0.54]
  • 21 to 35 [0.54-0.92]
  • 36 to 60 [0.93-1.55] (normal)
  • Over 60 [1.55]

Q960

Cholesterol, LDL. What is your fasting LDL cholesterol level? Unit: mg/dL [mmol/L]
  • Don't know
  • Under 100 [2.59] (normal/optimal)
  • 100 to 130 [2.59-3.38] (borderline high)
  • 131 to 160 [3.39-4.14] (high)
  • Over 160 [4.14] (very high)

Q961

Homocysteine (plasma). Unit: umol/L
  • Don't know
  • Under 5
  • 5 to 9.9 (optimal)
  • 10 to 14.9 (elevated)
  • 15 or higher

Q962

Iron, serum. Unit: ug/dL [umol/L]
  • Don't know
  • Under 20 [3.6] (very low)
  • 20-59 [3.6-10.6] (low)
  • 60-175 [10.7-31.3] (normal)
  • Over 175 [31.3] (high)

Q963

Iron, TIBC (Total Iron Binding Capacity). Unit: ug/dL [umol/L]
  • Don't know
  • Under 150 [26.9]
  • 150-239 [26.9-42.8]
  • 240-450 [42.9-80.6] (normal)
  • Over 450 [80.6]

Q964

Ferritin. Unit: ng/mL [pmol/L]
  • Don't know
  • Under 10 [22]
  • 10-17 [22-39]
  • 18-270 [40-607] (normal)
  • Over 270 [607]

Q965

Liver Enzymes. Are your liver enzymes elevated?
  • Don't know
  • No (they are normal)
  • In the past only
  • Currently slightly
  • Current significantly

Q966

Occult blood. Have lab tests found blood in your stool within the past 6 months?
  • Not tested within past 6 months / don't know
  • No, stool tested negative
  • In the past only, now resolved
  • Yes, trace or small amounts
  • Yes, enough for doctor to be concerned

Q967

Triglycerides, fasting. Unit: mg/dL [mmol/L]
  • Don't know
  • Under 40 [0.45]
  • 40 to 199 [0.45-2.25] (normal)
  • 200 to 600 [2.26-6.78]
  • Over 600 [6.78]

Q968

Uric acid (plasma). Unit: mg/dL [umol/L]
  • Don't know
  • Under 3.5 [210]
  • 3.5 to 4.5 [210-270]
  • 4.6 to 7.0 [280-420] (normal)
  • Over 7.0 [420]

LABORATORY VALUES – HORMONES

Please note any known results, even if all you know is that they were "normal".  Skip all questions that you are uncertain of.

Q969

If your DHEA level has been measured, what was the result?
  • Don't know
  • Definitely low
  • Reduced
  • Normal
  • Elevated

Q970

If your estrogen levels have been measured, what was the result?
  • Don't know
  • Very low
  • Somewhat low
  • Normal
  • Elevated

Q971

What are your melatonin levels when you are not using supplemental melatonin?
  • Don't know
  • Very low
  • Low
  • Normal
  • Elevated

Q972

If your progesterone levels have been measured, what was the result?
  • Don't know
  • Very low
  • Reduced (somewhat low)
  • Normal
  • High

Q973

If your Sex Hormone Binding Globulin (SHBG) level has been measured, what was the result?
  • Don't know
  • Very low
  • Somewhat low
  • Normal
  • Elevated

Q974

What are your testosterone levels when you are not using supplemental testosterone?
  • Don't know
  • Extremely low
  • Reduced (low)
  • Normal
  • Elevated

Q975

T3 (Free). Unit: pg/mL [pmol/L]
  • Don't know
  • Under 1.4 [0.021] (very low)
  • 1.4 to 2.0 [0.021-0.031] (low)
  • 2.1 to 4.4 [0.032-0.068] (normal)
  • Over 4.4 [0.068] (elevated)

Q976

T4 (Total). Unit: ug/dL [nmol/L]
  • Don't know
  • Under 4.5 [58] (low)
  • 4.5 to 5.9 [58-76] (low - normal)
  • 6.0 to 11.5 [77-148] (normal)
  • Over 11.5 [148] (elevated)

Q977

T4 (Free). Unit: ng/dL [pmol/L]
  • Don't know
  • Under 0.4 [5] (very low)
  • 0.4 to 0.8 [5-10] (low)
  • 0.9 to 2.0 [11-26] (normal)
  • Over 2.0 [26] (elevated)

Q978

Have you had your thyroid function tested within the last year? The usual test is for TSH (Thyroid Stimulation Hormone). Unit: uIU/mL or mIU/L
  • Don't know
  • Under 1.0 (low - too much thyroid activity)
  • 1.0 to 3.4 (normal)
  • 3.5 to 6.9 (early / marginal elevation)
  • Over 7.0 (elevated - not enough thyroid activity)

LABORATORY VALUES – NUTRIENTS

Please note any known results, even if all you know is that they were "normal".  Skip all questions that you are uncertain of.

Q979

Vitamin B6 (pyridoxine). Unit: ng/mL [nmol/L]
  • Don't know
  • Confirmed deficiency in the past
  • Under 4 [16] (low)
  • 4 to 18 [16-73] (normal)
  • Over 18 [73] (elevated)

Q980

Vitamin B12 (cobalamin). Unit: pg/mL [pmol/L]
  • Don't know
  • Confirmed deficiency in the past
  • Under 200 [150] (low)
  • 200-950 [150-700] (normal)
  • Over 950 [700] (elevated)

Q981

Urine MMA. Normal levels are below 3.8ug of MMA per mg of creatinine (below 3.6umol MMA per mmol of creatinine); Elevated levels are anything above this.
  • Don't know
  • Normal
  • Elevated

Q982

Folic Acid. Unit: nmol/L
  • Don't know
  • Confirmed deficiency in the past
  • Under 10 (low)
  • 10 to 30 (normal)
  • Over 30 (elevated)

Q983

Tryptophan. If your blood or urine tryptophan levels have been measured within the past 3 months, what was the result?
  • No / over 3 months ago / don't know
  • Very low
  • Low
  • Normal
  • Elevated

LABORATORY VALUES – X-RAYS & SCANS

Note any known results, even if they were simply "normal".  Skip all questions that you are uncertain of.  Any scans not mentioned here can be listed on the final page of this questionnaire.

Q984

Has a bone scan, X-ray or specialty urine test indicated that bone loss (Osteoporosis) is a problem for you?
  • Have not had this test / don't know
  • No bone loss indicated (normal)
  • Bone loss indicated / not currently losing bone
  • Bone loss indicated / currently losing bone
  • Significant loss indicated / losing at a high rate

Q985

Chest X-ray. If you have had one within the past year, what was the result? If abnormal, please add a note detailing any heart, lung, bone or tissue abnormalities that were found.
  • I have not had one (recently) / don't know
  • Normal, and I have never had an abnormal one
  • Normal, but I have had previous abnormal one(s)
  • It was my first abnormal one
  • Abnormal, and I have had previous abnormal one(s)

OTHER DIAGNOSTIC TESTS

Q986

Have you tried the Iodine Patch Test within the past 6 months? If so, how long did it take for the iodine patch to disappear after it was painted on your arm?
  • Never tried it / over 6 months ago / don't know
  • Less than 4 hours
  • 4 to 8 hours
  • 9 to 12 hours
  • It lasts at least 12 hours (normal)

Q987

Zinc Taste Test. If you have tried this test within the past 6 months, what was your sensation?
  • Never tried it / over 6 months ago / don't know
  • Tasteless
  • Distinctly dry, metallic, fuzzy, sweet
  • Slowly becoming objectionable (normal)
  • Rapidly objectionable
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