Female Hormone Questionnaire

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.