Female Hormone Questionnaire
Name: Click here to enter text. DOB: Click here to enter text. Date: Click here to enter text. Email: Click here to enter text.
This questionnaire assesses your sex hormone function. Your sex hormones maintain youthful health and prevent many diseases of aging. They are important for sexual characteristics, sex organ function and sexual activity, but also for muscle, heart, brain, blood vessel and so many other functions. You can tell this by many of the symptoms listed below. The more items checked below in a hormone category, the greater the possibility you have a deficiency of that hormone. Certain symptoms/associations have a higher likelihood than others.
Please mark the box of any that apply. Indicate the severity of each symptom you are experiencing currently by typing a 1 – 5 (1=mild/5=severe) in the middle of the red line ( __ ). Some questions may not sound as if they are requesting severity information or you may be unsure of the severity. In these situations please enter your best guess. If the symptom is current, simply place a number in the provided space. If it is a symptom that you have had in the past, please indicate severity & type the word “past” in the space.
Hysterectomy ☐Yes ☐No
If Yes ☐Partial ☐Total
Date: Click here to enter text.
Menstruation
Regular Menses ☐Yes ☐No
Average # of days in cycle Click here to enter text.
Blood Draw Day Click here to enter text. of cycle
Hormone Replacement ☐Yes ☐No
Name Click here to enter text.
Dose and Frequency Click here to enter text.
Name Click here to enter text.
Dose and Frequency Click here to enter text.
Lack of Estrogen
__Fatigue (continuous)
__Depression (continuous)
__Memory loss
__Difficulty concentrating
__Decreased sex drive
__Hot flashes
__Night sweats
__Sleep disorders (hot flashes & night sweats)
__Vulvar/Vaginal shrinkage
__Vaginal itching
__Vaginal dryness
__Painful intercourse
__Dry skin
__Dry eyes
__Dry mouth
__Lack of menstruation
__Scanty menstruation
__Short or long menstrual cycle
__Recurrent bladder infections
__Prolapse bladder, uterus, vagina, rectum
__Cyclical Headaches/Migraine
__Pale face & skin
__Hollow face
__Sharp small wrinkles lips, eyes, hands, skin
__Small breasts
__Breast ptosis (drooping)
__Infertility
__Premature aging
__Osteopenia/Osteoporosis
__Heart disease
__Alzheimer's disease
__Insulin resistance/ Type 2 DM
__Abnormal cholesterol
__Increased blood pressure
__Cataracts
__Macular degeneration
__Colon cancer
Lack of Progesterone
__Nervous tenseness
__Muscle tenseness
__Anxiety
__Irritability
__Aggressiveness
__Anger
__Rage
__Lack of tolerance to stress (adrenalin blocks progesterone receptors)
__Sensitivity to pain
__Increased expression of pain
__Insomnia
__Swollen belly
__Painful belly to touch
__Bloating
__Premenstrual abdominal bloating
_Increased abdominal fat
__Weight gain
__PMS
__PMDD
__Cyclical Headache/Migraine
__Cyclical Seizures
__Premenstrual Headache/Migraine
__Premenstrual Moodiness/Mood swings
__Premenstrual Inability to concentrate
__Premenstrual Fuzzy ☐ thinking
__Premenstrual Depression
__Large breasts
__Swollen breasts
__Painful breasts
__Breast cysts (Fibrocystic breast)
__Breast cancer
__Early menstruation
__Heavy menstruation
__Cramps
__Painful menstruation
__Pain on deep intercourse (Endometriosis)
__Endometriosis
__Endometrial hyperplasia
__Endometrial cancer
__Fibroids
__Enlarged uterus
__Ovarian cysts
__Reddish face & skin
__Swollen face & skin
__Swollen feet & ankles
__Infertility
__Preeclampsia
__Miscarriage
__Premature delivery
__Thinning hair
__Hypothyroid symptoms
__Abnormal lipids
__Increased blood pressure with stress (adrenalin blocks progesterone receptors)
__Low libido
__Food cravings – sweet
Lack of Testosterone
__Nervous
__Irritable
__Ill at ease
__Lack of mental firmness
__Undecided, Hesitating
__Lack of self-confidence
__Lack of assertiveness
__Lack of authority
__Submissive
__Frequent complaints of illness
__Aging appearance
__Abdominal weight gain despite exercise
__Abdominal Obesity/Overweight
__Excess fat in breasts & hips
__Muscle laxity
__ Day & night sweats (head & upper chest
__Hot flashes
__Fatigue that increases with physical activity
__Lack of Energy
__Tire easily
__Lack of interest in exercise
__Lack of endurance
__Depression (continuous)
__Negative attitude
__Anxiety, fears
__Excessive emotions with stress
__Low resistance to stress
__Excessive sensitivity to difficulties
__Reduced muscle strength
__Reduced muscle mass
__Muscle pains
__Back pain
__Sciatica
__Joint pain
__Easy sun-burn
__Urinary incontinence
__Decrease in sex drive
__Decreased nipple sensitivity
__Decreased clitoral size & sensitivity
__Decreased orgasm
__Vaginal itching
__Vaginal atrophy
__Vaginal dryness
__ Painful intercourse
__Lack or loss of sexual body scent
__Loss of height
__Slumped, fragile appearance
__Kyphosis, lordosis (excessive spine curvature)
__Pale skin
__Aging face
__Small wrinkles lips & eyes
__Thin lips
__Dry skin
__Thin skin
__Atrophic skin
__Dry eyes
__Decreased armpit, pubic & body hair
__Cellulite
__Varicose veins
__Easy bruising
__Poor Concentration
__Poor memory
__Joint disease
__Osteoporosis
__Atherosclerosis
Please email this completed form to . If you have any questions or wish to make an appointment, please call 727-202-6807.