Female Hormone Questionnaire

Female Hormone Questionnaire
Name*

First NameLast Name
Date Completed*

MonthDayYear
Date
Progesterone Deficiency
Please check all that apply

AnxietyDecreased libido or sex driveDepressionExcessive menstrual bleedingEmotional labilityInsomniaIrritabilityHistory of miscarriageMigraine headaches associated with the menstrual cycleMood swingsOsteopenia/osteoporosisWeight gain
Please check all that apply

Use of antidepressantsHistory of hypothyroidismZinc deficiencyVitamin-A deficiencyVitamin B6 deficiencyHigh sugar dietLow prolactin
Progesterone Excess
Please check all that apply.

Urinary incontinenceLaxity of ligaments ( back pain, achy hips )Decreased glucose toleranceIncreased appetiteIncreased carbohydrate cravingsIncreased fat storageAbdominal bloating, constipationGallstonesImmune system dysfunction
Estrogen Excess (Dominance)
Please check all that apply.

Abdominal bloatingCervical dysplasia (abnormal Pap smear)Decreased sex driveDepression with anxiety or agitationFatigueFibrocystic breast disease / fibroadenomaHeavy menstrual cyclesHypothyroidismIrritabilityMood swingsPanic attacksInsomniaBreast swelling or tendernessUterine fibroidsWater retentionWeight gain
Estrogen Deficiency
Please check all that apply.

AcneJoint pains/ arthritisAnxietyLow energyAging of the skin, wrinklesBrittle hair and nailsOily skinChronic fatigueOsteopenia/osteoporosisPanic attacksDecreased memory /cognitive declineDecreased sex driveRestless sleepDepressed moodUrinary stress incontinenceInfertilityAbdominal weight gainDry eyesUrinary tract infectionsVaginal drynessIncreased facial hairHigh cholesterol
Testosterone Deficiency
Please check all that apply.

AnxietyDecreased muscle toneDecreased sex driveDroopy eyelidsDry, thin skinDry, thinning hairFatigueHyper emotional statesLow self-esteemDepressed moodMuscle wastingThin lipsWeight gain ( body fat)
Please check all that apply.

Oral contraceptive therapyChemotherapyStatins ( cholesterol-lowering medication)DepressionPsychological traumaHysterectomy
Testosterone Excess
Please check all that apply.

AcneOily skinAgitationAngerImpaired memoryDepressionFatigueFluid retentionHair lossFacial hairHypoglycemia ( low blood sugar)InfertilityIrregular menstrual cyclesMood swingsSalt cravingsSugar cravingsWeight gain ( body fat)
DHEA Deficiency
Please check all that apply.

Decreased energyDecreased muscle strength and staminaDifficulty dealing with stressFrequent infectionsIrritabilityJoint sorenessWeight gain ( body fat)
DHEA Excess
Please check all that apply.

AcneAngerDeepening of voiceDepressionFacial hairFatigueInsomniaIrritabilityMood changesRestless sleepSugar cravingsWeight gain ( body fat)
Last Mammogram ( date completed )

MonthDayYear
Mammogram Results
Last Pap Smear ( date completed )

MonthDayYear
Pap smear Results
Should be Empty:

Female Hormone Questionnaire

Progesterone Deficiency

Progesterone Excess

Estrogen Excess (Dominance)

Estrogen Deficiency

Testosterone Deficiency

Testosterone Excess

DHEA Deficiency

DHEA Excess