Women's Hormonal Health Symptom Questionnaire

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Welcome

Let's check your symptoms:

10Questions

1
Full Name* This field is required.
First Name
Last Name
2
Email Address
example@example.com
3
What is your age?
4
Do you use birth control?
Yes
No
5
What type of birth control do you use?
Please Select
Please Select
Birth control pill
IUD
Implant
Injection
Patch
Vaginal ring
Condoms
Fertility awareness
Other
6
Are your menstrual cycles irregular?* This field is required.
Yes
No
Not applicable
7
Which of these symptoms are you currently experiencing?* This field is required.
Irregular periods
Heavy periods
Skipped periods
Hot flashes
Night sweats
Vaginal dryness
Low libido
Acne
Hair thinning or hair loss
Facial hair growth
Weight gain
Fatigue
Brain fog
Constipation
Cold intolerance
Other
8
Please rate the following symptoms over the past 3 months:* This field is required.
None
Mild
Moderate
Severe
Hot flashes
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Night sweats
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Mood swings
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Anxiety
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Depression
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Sleep disturbances
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Vaginal dryness
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Low libido
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Fatigue
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Weight changes
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Headaches
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Hot flashes
Night sweats
Mood swings
Anxiety
Depression
Sleep disturbances
Vaginal dryness
Low libido
Fatigue
Weight changes
Headaches
None
Row 0, Column 0
Mild
Row 0, Column 1
Moderate
Row 0, Column 2
Severe
Row 0, Column 3
None
Row 1, Column 0
Mild
Row 1, Column 1
Moderate
Row 1, Column 2
Severe
Row 1, Column 3
None
Row 2, Column 0
Mild
Row 2, Column 1
Moderate
Row 2, Column 2
Severe
Row 2, Column 3
None
Row 3, Column 0
Mild
Row 3, Column 1
Moderate
Row 3, Column 2
Severe
Row 3, Column 3
None
Row 4, Column 0
Mild
Row 4, Column 1
Moderate
Row 4, Column 2
Severe
Row 4, Column 3
None
Row 5, Column 0
Mild
Row 5, Column 1
Moderate
Row 5, Column 2
Severe
Row 5, Column 3
None
Row 6, Column 0
Mild
Row 6, Column 1
Moderate
Row 6, Column 2
Severe
Row 6, Column 3
None
Row 7, Column 0
Mild
Row 7, Column 1
Moderate
Row 7, Column 2
Severe
Row 7, Column 3
None
Row 8, Column 0
Mild
Row 8, Column 1
Moderate
Row 8, Column 2
Severe
Row 8, Column 3
None
Row 9, Column 0
Mild
Row 9, Column 1
Moderate
Row 9, Column 2
Severe
Row 9, Column 3
None
Row 10, Column 0
Mild
Row 10, Column 1
Moderate
Row 10, Column 2
Severe
Row 10, Column 3
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9
How would you rate your overall symptom burden over the past 3 months?* This field is required.
1
2
3
4
5
6
7
8
9
10
Not bothered by symptoms at all
Overwhelmingly High
10
Please share any additional symptoms or concerns related to your menstrual cycle, mood, energy, or thyroid health.
Should be Empty:

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