HORMONE QUESTIONNAIRE

HORMONE QUESTIONNAIRE (for clients only)

First Name

Last Name

Date

Section 1

Please select all that apply to you (don't spend too long thinking about things and go with what happens the most frequently or recently, rather than your full health or menstrual history).

Skin conditions such as eczema or thin skin (also emotionally thin skin)

Bone loss or conditions such as osteopenia, osteporosis, or arthritis

Do you feel you are constantly going from one the to another without a break.

Difficulty falling asleep

Disrupted sleep (do you wake up at the same time each night).

Do you need a glass of wine (or other alcohol) to unwind in the evening?

Do you need caffeine or sugary foods (including breakfast cereals and anything containing refined flour such as pastries, bread) to get going in the morning?

Generally feeling anxious or nervousness - worrying about thins beyond your control.

Quickness to anger or rage with frequent screaming or yelling.

Memory lapses of felling distracted, especially under pressure from others.

High blood sugar or diagnosis or suggestion of insulin resistance, pre-diabetes of PCOS

Shakiness in between meals

Increased abdominal circumference, (muffin top or apple shape that isn't bloating). Waist siye more than 35 inches or 100cm.

High blood pressure.

Rapid heartbeat when at rest (100 beats per minute or greater).

Indigestion, stomach ulcers or reflux.

Difficulty recovering from an injurz compared to in the past.

Unexplained stretch marks (pink or purple) on your belly or back.

Very long or short menstrual czcles

Irregular menstrual cycles (variation of a cycle length more that 2 days each cycle)

Heavy bleeding

Spotting

Lots of cervical fluid

No cervical fluid

Not ovulating or delayed ovulation

Shortened luteal phase (the gap between confirmed ovulation and the start of your period is less than 12 days).

Section 2

Please select all that apply to you (don't spend too long thinking about things and go with what happens the most frequently or recently, rather than your full health or menstrual history).

Fatigue or burnout. (Do you fall asleep when reading a book or watching TV or need a caffeine boost to continue what should be a normal activity?)

Loss of stamina or afternoon slump (feeling tired, fed up with your job or needing a caffeine or food boost mid afternoon, especiallz around 3-3.30).

You are seeing the negative point of view more often than the positive or the upside.

Crying for no reason, or reasons that seem important and valid at the time (but afterwards you feel it was a bit trivial or embarrassed).

Decreased problem solving ability everything feel like such a big hurdle.

Feeling stressed most of the time?

Everything feels so much harder (even things that you could do before not preblem).

Postural hypotension (feeling dizzy when standing up too quickly or when in a hot bath).

Difficulty recovering from illness, surgery or wounds.

Asthma, chronic allergies, cough that never goes away, post nasal drip, sinus congestion

Low or unstable blood sugar.

Salt cravings.

Excess seating that doesn't match your activity levels or environment.

Muscle weakness, especially around the knee, muscle or joint pain.

Hemorrhoids or varicose veins.

Your blood seems to pool easily or your skin bruises easily.

A thyroid problem that when treated you suddenly get palpitations or have rapid or irregular heart beats?

Irregular cycles.

No period or rare periods.

Very heavy or very light periods.

Section 3

Please select all that apply to you (don't spend too long thinking about things and go with what happens the most frequently or recently, rather than your full health or menstrual history).

Agitation or PMS

Cyclical headaches (particularly around menstruation, ovulation or hormonal migraines)

Painful or swollen breasts

Irregular menstrual cycles or cycles becoming more frequent as you get older (cycles getting shorter).

Heavy or painful periods (changing a high flow rate menstrual product less than every 2 hours.

Bloating or fluid retention, especially around the belly or ankles.

Putting on wieght leading up to and around your period (more than 3 ibs/1.4 kg)?

Ovarian cysts, breast cysts or endometrial cysts (polyps)?

Easily disrupted sleep/staying asleep.

Difficulty going to sleep

Itchy or restless legs, especially at night

Increased clumsiness or co-ordination issues.

Infertility or sub fertility..

Miscarriage in first trimester.

Short luteal phase (the gap between confirmed ovulation and the start of your period is-less than 12 days).

Low temperature rise after ovulation (less than 0.2 degrees C or 0.3 degrees F) if you chart.

Section 4

Please select all that apply to you (don't spend too long thinking about things and go with what happens the most frequently or recently, rather than your full health or menstrual history).

Bloating, puffiness or water retention.

Allergies, food sensitivities.

Abnormal smear tests.

Heavy bleeding or flooding.

Rapid weight gain around thighs and bottom.

Increased breast tenderness.

Going up a cup size without putting on weight elsewhere.

Long periods, heavy periods or bleding between periods

Dark coloured period (deep red, purple, brown or black)

Lots of cervical fluid throughout the month.

Fibroids.

Endometriosis, suspected endometriosis or painful periods.

Shortened luteal phase.

Moodswings, depression, irritability or PMS

Weepiness, sometimes over the most trivial things or nothing at all.

Mini breakdowns or anxiety.

Migraines or other headaches.

Insomnia.

Brain fog.

Rosacea or constantly red flushes face.

Gall bladder problems (or maybe its been removed).

Section 5

Please select all that apply to you (don't spend too long thinking about things and go with what happens the most frequently or recently, rather than your full health or menstrual history).

Poor memory/brain fog (getting lost in the diddle of a sentence or forgetting what you were doing, losing your train of thought, or forgetting what it was you were looking for).

Emotional fragility (more so now than when you were younger).

Depression, anxiety or lethargy. (Two points if it has lasted more than two weeks).

Wrinkles that no matter what beauty products you try.

Dry eyes.

Dry skin

Sun damage to face, neck shoulders, décolletage or hands.

Droopy or saggy breasts that are getting smaller in volume.

Night sweats or hot flashes.

Trouble sleeping, waking up in the middle of the night.

Leaky or overactive bladder or bladder infections.

Achy joints.

Recent injuries to shoulders, back, knees or wrists.

Bone loss

Vaginal dryness/low cervical fluid.

Low libido.

Painful sex

Light or thin periods.

Varied flow periods.

Pink or orange periods.

Section 6

Please select all that apply to you (don't spend too long thinking about things and go with what happens the most frequently or recently, rather than your full health or menstrual history).

Excess hair on your face, chest or arms

Thinning hair particularly on the top of your head or female pattern baldness.

Greasy skin and/or hair

Discolouration of armpits (darker skin than elsewhere).

Skin tags on neck, face or torso.

Hyper of hypoglycaemia, unstable blood sugar levels.

PCOS, insulin resistance,pre diabetes, type 2 diabetes or metabolic syndrome (diagnosed or suspected).

Depression or anxiety.

Reactivity, aggressiveness or irritability

Long or irregular cycles

Ovarian cysts.

Mid cycle pain.

Infertility or sub fertility.

Lots of cervical fluid throughout the month.

Very high or low libido.

Heavy or irregular periods.

Lack of ovulation.

Apple shape - putting on of weight around the belly.

Unstable to shift weight no matter how much cardio you do.

Section 7

Please select all that apply to you (don't spend too long thinking about things and go with what happens the most frequently or recently, rather than your full health or menstrual history).

Hair loss all over your head, and particularly noticeable in the other third of eyebrows.

Dry, straw like hair.

Dry skin.

Thin brittle nails that break easily and won't grow.

Weight gain that won't go, no matter what you do.

High cholesterol.

Bowel movements less often than once a day or don't feel you have completely emptied

Recurrent headache

Decreased sweating

Muscles or doing aches or poor muscle tone.

Tingling in your hands or feet.

Cold hands and feel. Cold or heat intolerance.

Slow brain, slow thoughts. Inability to concentrate on anything for long.

Slow reflexes.

Low libido.

Depression or moodiness. (Worse than when you were younger).

Anti-depressant use but you don't feel like you.

Heavy periods.

Dark periods (dark red, brown, black, blue or purple)

Infertility, sub fertility or miscarriage. Preterm birth.

Enlarged thyroid or goitre.

Difficulty swallowing or enlarged tongue.

Family history of thyroid problems.

Lots of cervical fluid.

Short Luteal Phase (less than 12 days).

Low BBT temps (especially pre-ovulation).

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