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.

Q937

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

Q938

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]

Q939

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]

Q940

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

Q941

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

Q942

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

Q943

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)

Q944

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)

Q945

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

Q946

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)

Q947

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)

Q948

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)

Q949

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)

Q950

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.

Q951

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)

Q952

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

Q953

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

Q954

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

Q955

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

Q956

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)

Q957

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]

Q958

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)

Q959

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

Q960

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)

Q961

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]

Q962

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

Q963

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

Q964

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

Q965

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]

Q966

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.

Q967

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

Q968

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

Q969

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

Q970

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

Q971

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

Q972

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

Q973

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)

Q974

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)

Q975

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)

Q976

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.

Q977

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)

Q978

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)

Q979

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

Q980

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

Q981

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.

Q982

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

Q983

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

Q984

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)

Q985

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