Female Hormone Questionnaire
Name
*
First Name
Last Name
Date Completed
*
-
Month
-
Day
Year
Date
Progesterone Deficiency
Please check all that apply
Anxiety
Decreased libido or sex drive
Depression
Excessive menstrual bleeding
Emotional lability
Insomnia
Irritability
History of miscarriage
Migraine headaches associated with the menstrual cycle
Mood swings
Osteopenia/osteoporosis
Weight gain
Please check all that apply
Use of antidepressants
History of hypothyroidism
Zinc deficiency
Vitamin-A deficiency
Vitamin B6 deficiency
High sugar diet
Low prolactin
Progesterone Excess
Please check all that apply.
Urinary incontinence
Laxity of ligaments ( back pain, achy hips )
Decreased glucose tolerance
Increased appetite
Increased carbohydrate cravings
Increased fat storage
Abdominal bloating, constipation
Gallstones
Immune system dysfunction
Estrogen Excess (Dominance)
Please check all that apply.
Abdominal bloating
Cervical dysplasia (abnormal Pap smear)
Decreased sex drive
Depression with anxiety or agitation
Fatigue
Fibrocystic breast disease / fibroadenoma
Heavy menstrual cycles
Hypothyroidism
Irritability
Mood swings
Panic attacks
Insomnia
Breast swelling or tenderness
Uterine fibroids
Water retention
Weight gain
Estrogen Deficiency
Please check all that apply.
Acne
Joint pains/ arthritis
Anxiety
Low energy
Aging of the skin, wrinkles
Brittle hair and nails
Oily skin
Chronic fatigue
Osteopenia/osteoporosis
Panic attacks
Decreased memory /cognitive decline
Decreased sex drive
Restless sleep
Depressed mood
Urinary stress incontinence
Infertility
Abdominal weight gain
Dry eyes
Urinary tract infections
Vaginal dryness
Increased facial hair
High cholesterol
Testosterone Deficiency
Please check all that apply.
Anxiety
Decreased muscle tone
Decreased sex drive
Droopy eyelids
Dry, thin skin
Dry, thinning hair
Fatigue
Hyper emotional states
Low self-esteem
Depressed mood
Muscle wasting
Thin lips
Weight gain ( body fat)
Please check all that apply.
Oral contraceptive therapy
Chemotherapy
Statins ( cholesterol-lowering medication)
Depression
Psychological trauma
Hysterectomy
Testosterone Excess
Please check all that apply.
Acne
Oily skin
Agitation
Anger
Impaired memory
Depression
Fatigue
Fluid retention
Hair loss
Facial hair
Hypoglycemia ( low blood sugar)
Infertility
Irregular menstrual cycles
Mood swings
Salt cravings
Sugar cravings
Weight gain ( body fat)
DHEA Deficiency
Please check all that apply.
Decreased energy
Decreased muscle strength and stamina
Difficulty dealing with stress
Frequent infections
Irritability
Joint soreness
Weight gain ( body fat)
DHEA Excess
Please check all that apply.
Acne
Anger
Deepening of voice
Depression
Facial hair
Fatigue
Insomnia
Irritability
Mood changes
Restless sleep
Sugar cravings
Weight gain ( body fat)
Last Mammogram ( date completed )
-
Month
-
Day
Year
Mammogram Results
Last Pap Smear ( date completed )
-
Month
-
Day
Year
Pap smear Results
Submit
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