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Hormone Questionnaire Patient Age Date Diagnosis Low Progesterone ☐ Anxiety ☐ Heavy Periods ☐ Difficulty handling stress ☐ Low Bone Density ☐ Elevated cortisol levels ☐ Recurring miscarriage ☐ Estrogen dominant conditions ☐ Water Retention ☐ Weight Gain on abdomen Excess Progesterone ☐ Breast Swelling and Pain ☐ Low libido ☐ Depression/ Low Mood ☐ Oily skin ☐ Excess Facial Hair ☐ Feeling tired or drowsy ☐ Hyper insulinemia Excess Estrogen Low Estrogen ☐ Brain Fog ☐ Painful Intercourse ☐ Recurring Urinary Tract Infections ☐ Urinary Incontinence ☐ Vaginal Dryness ☐ Thinning of the Vaginal Wall ☐ Acne ☐ Gallstones ☐ Anemia ☐ Irritability ☐ Asthma intensified ☐ Loss of sex drive ☐ Depression ☐ Memory loss ☐ Estrogen dominant conditions ☐ Fatigue ☐ Period Problems (irregular, long, short, heavy) ☐ Fluid retention ☐ PMS ☐ High cortisol ☐ Loss of strength and stamina ☐ Low DHEA from low testosterone ☐ Low or no sex drive ☐ Memory decline ☐ Weight Gain Excess Testosterone/ DHEA Low Testosterone/ DHEA ☐ Fatigue ☐ Raging Hot flashes and night sweats that donʼt abate with treatment ☐ Muscle wasting and weakness (chin mmʼs start sagging) ☐ Acne, oily skin ☐ Osteopenia ☐ High DHEA ☐ Osteoporosis ☐ Ovarian cysts (PCOS) ☐ Sleep Problems ☐ Resistance to insulin ☐ Vaginal dryness ☐ Weight Gain ☐ Facial hair growth ☐ Hair loss Adrenal Stress ☐ Alcohol Intolerance ☐ Edema of Extremities ☐ Hypoglycemia ☐ Asthma/ Bronchitis ☐ Environmental Sensitivities ☐ Low Back Pain ☐ Blurred Vision ☐ Excessive Perspiration ☐ Low energy, excessive fatigue ☐ Cold Extremities ☐ Excessive Urination ☐ Increase/loss of skin pigmentation (advanced case looks like sun tan) ☐ Cravings for Stimulants (Salt, junk food, coffee) ☐ Eyes light sensitive ☐ Food allergies ☐ Inflammation and joint or muscle pain ☐ Depression ☐ Headaches ☐ Insomnia (secondary) ☐ Digestive Problems ☐ Heart Palpitations ☐ Irritability ☐ Dizziness Upon Rising ☐ HIgh cortisol ☐ Knee Problems ☐ Ulcers ☐ Poor Concentration ☐ Post-exertion fatigue ☐ Recurring infections Excess Cortisol Low Cortisol ☐ Burned out feeling ☐ Difficulty handling stress ☐ Feel like you are pushing yourself through the day. ☐ Increased infections ☐ Muscle Twitches ☐ Nervous Anxiety ☐ Tired Feet ☐ Allergies ☐ Low thyroid ☐ Low blood pressure ☐ Morning tiredness ☐ Muscle stiffness ☐ Hair loss ☐ Low sex drive ☐ High Blood Pressure ☐ Low thyroid ☐ High Insulin ☐ Mood swings and depression ☐ Insulin Resistance ☐ No sex drive ☐ Sensitivity to cold ☐ Irritable/ Anxiety ☐ Osteoporosis ☐ Low DHEA ☐ Poor Immune Function ☐ Low Progesterone ☐ Weight Gain ☐ Wired but Tired Feeling Low Thyroid Function ☐ Metallic Taste in Mouth ☐ Dry coarse skin and hair ☐ Impaired Memory ☐ Racing thoughts ☐ Anemia ☐ Edema (swelling of eyelids) ☐ Anxiety/ Nervousness ☐ Elevated cholesterol ☐ Infertility and/or recurring miscarriage ☐ Chronic Fatigue, weakness ☐ Feeling of being unable to breath deeply ☐ Insomnia ☐ Severe menopause symptoms that last years without relief ☐ Goiter ☐ Low P:E ratio ☐ Constipation ☐ Hair loss ☐ Low T3, T4 or T7 ☐ Cracking in heels and skin ☐ Headaches and Dizziness ☐ Night sweats ☐ Depression and Irritability ☐ Heart Palpitations ☐ Poor Concentration ☐ Doughy Abdomen ☐ High TSH over 2.0 ☐ Poor Vision ☐ Hormone Imbalances ☐ Presence of thyroid Abʼs ☐ Cold hands and feet, cold intolerance ☐ Low basal Temperature ☐ Shortness of Breath ☐ Slow Pulse ☐ Slow metabolism (hip weight gain) ☐ Sudden change in personality Overactive Thyroid Function ☐ Breathlessness ☐ Muscle Weakness ☐ Fatigue ☐ Nervousness ☐ Hair Loss ☐ Staring Gaze (bulging eyes) ☐ Heart Palpitations ☐ Heat Intolerance ☐ Increased Bowel Movʼts ☐ Insomnia ☐ Light or Absent Menstrual Periods ☐ Trembling hands ☐ Warm, moist skin ☐ Weight loss ☐ Goiter Symptoms of Peri Menopause ☐ 35 or older Symptoms of Menopause ☐ Reduced Libido ☐ Hot flashes and/or night sweats ☐ Endometriosis ☐ Secondary Insomnia ☐ Fibroid breast cysts ☐ Keep forgetting things ☐ Gained 10lbs and abdomen is bloated ☐ PMS symptoms ☐ Headaches ☐ Thinning hair ☐ Feeling anxious, irritable and tire easily ☐ Heavy Period, clotting or longer periods ☐ Uterine Fibroids ☐ gained weight ☐ Skin outbreaks/acne ☐ 45 or older ☐ Have not had a period for 12 months or longer ☐ Do not have a desire for sex ☐ Hot flashes and or night sweats ☐ Intercourse is painful ☐ Leaking urine ☐ Memory problems and brain fog ☐ Primary and secondary insomnia ☐ Skin is excessively dry and wrinkled ☐ Vaginal dryness and Questionnaire taken from Lorna Vanderhaegheʼs book “Sexy Hormones”