Download Hormone Questionaire

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”