Hormone Balance Screening Questionairre

Hormone Balance Questionairre
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
E-mail*

Confirmation Email
Birth Date*

MonthDayYear

Group 1*

	Never or almost never(0)	Ocassionaly, not severe (1)	Ocassionally, severe (2)	Frequently, not severe (3)	Frequently Severe (4)
PMS
Insomnia
Early Miscarriage
Painful/Lumpy Breasts
Unexplained Weight Gain
Cyclical Headaches
Anxiety
Infertility

Group 2*

	Never or almost never(0)	Ocassionaly, not severe (1)	Ocassionally, severe (2)	Frequently, not severe (3)	Frequently Severe (4)
Vaginal Dryness
Night Sweats
Painful Intercourse
Memory Problems
Bladder Infections
Lethargic Depression
Hotflashes

Group 3*

	Never or almost never (0)	Ocassionaly, not severe (1)	Ocassionally, severe (2)	Frequently, not severe (3)	Frequently Severe (4)
Puffiness or Bloating
Cervical Dysplasia
Rapid Weight Gain
Breast Tenderness
Mood Swings
Heavy Bleeding
Anxious Depression
Migraine Headaches
Insomnia
Foggy Thinking
Red Flush onf Face
Gallbladder Problems
Weepiness

Group 5*

	Never or almost never (0)	Ocassionaly, not severe (1)	Ocassionally, severe (2)	Frequently, not severe (3)	Frequently Severe (4)
Acne
PCOS
Excessive Hair on the face and/or arms
Hypoglycemia/low blood sugar
thinning hair
infertility
ovarian cysts
midcycle pain

Group 6*

	Never or almost never (0)	Ocassionaly, not severe (1)	Ocassionally, severe (2)	Frequently, not severe (3)	Frequently Severe (4)
Debilitating Fatigue
unstable blood sugar
foggy thinking
low blood pressure
thinning or dry skin
intolerance to exercise
Brown Spots on Face

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