Female hormone questionnaire
Have you had a hysterectomy? ( ) Yes ( ) No
Do You ...
[ ] Have a history of antibiotic use
[ ] Continuously use prescription medication
[ ] Take synthetic hormones in topical cream, patch or orally
[ ] Experience difficulty sleeping
[ ] Experience mood swings
[ ] Experience hot flashes
[ ] Experience low libido
[ ] Drink more than one glass of alcohol weekly
[ ] Drink caffeine daily
[ ] Experience Exhaustion
[ ] Experience irregular menstrual cycle
[ ] Experience infertility
[ ] Experience frequent urination
Menstrual or Menopause Concern
Ovarian Dysfunction — Do You Have ...
[ ] Vaginal dryness, pain
[ ] Painful intercourse
[ ] Engorged breasts
[ ] Milk production (not nursing)
[ ] Lack of interest in sex
[ ] Blurred vision
[ ] Headache
[ ] Acne and/or oily skin
[ ] Aggressive feelings
[ ] Overwhelming sexual urges
[ ] Absence of menstrual flow for six or more months
[ ] Occasionally skip periods
[ ] Menstruation began after 16 years old
[ ] Breasts shrinking
[ ] Thinning pubic and armpit hair
[ ] Unable to get pregnant
[ ] Miscarriage
[ ] Excess facial hair
[ ] Poor sense of smell
[ ] Monthly abdominal pain without bleeding
[ ] Menstrual type pain between menses
[ ] Irregular time intervals between periods
[ ] Menstrual cycles greater than 32 days
[ ] Menstrual cycles less than 24 days
[ ] Vaginal bleeding between periods
[ ] Pain during periods is getting progressively worse
[ ] Pain, cramps
Premenstrual Syndrome
(3 days - 2 weeks prior to menstruation) Do You Have ...
[ ] Premenstrual tension
[ ] Painful menses (cramping etc.)
[ ] Menstruation excessive or prolonged
[ ] Painful/tender breasts
[ ] Menstruate too frequently
[ ] Acne, worse at menses
[ ] Depressed feelings before menstruation
[ ] Vaginal discharge
[ ] Menses scanty or missed
[ ] Hysterectomy/ovaries removed
[ ] Depression
[ ] Insomnia
[ ] Abdominal bloating
[ ] Breast tenderness, swelling
[ ] Depressed, irritable, nervous
[ ] Easy to anger, resentful
[ ] Easily overwhelmed
[ ] Nausea and/or vomiting
[ ] Diarrhea or constipation
[ ] Headache
[ ] Food cravings, binge eating
[ ] Back pain
[ ] Feel faint
[ ] Clumsiness
[ ] Forgetful
[ ] Weight gain-water
[ ] Suicidal
Dysplasia / Fibrocystic Syndrome
Do You Have ...
[ ] Lumps are painful, tender
[ ] Clear, gray or yellow vaginal discharge
[ ] Vaginal bleeding after sex or between periods
[ ] Burning or itching or external genitalia
[ ] Urgent, painful urination
[ ] Lower abdominal or back pain
[ ] Heavy, watery and bloody vaginal discharge
[ ] Heavy menstrual flow
[ ] Pelvic cramps
[ ] Thin, scant white vaginal discharge
[ ] Greenish yellow or offensive discharge
[ ] Cheesy white discharge
[ ] Breast lumps or swelling
[ ] Lumps hurt just before period
[ ] Swelling under armpit
[ ] Change in breast size, shape
[ ] White or slightly bloody vaginal discharge, one week prior to period
[ ] Current diagnosis of fibrocystic breast disease
Menopause
Do You Have ...
[ ] Irregular menstrual cycle
[ ] Menstruation excessive or prolonged
[ ] Menstruation too frequent
[ ] Acne, worse at menses
[ ] Menses scanty or missed
[ ] Hysterectomy / ovaries removed
[ ] Dry skin, hair, vagina
[ ] Lack of interest in sex
[ ] Mood swings, irritable
[ ] Depression, anxiety, nervousness
[ ] Craving for sweets, binge eating
[ ] Headaches or dizziness
[ ] Painful intercourse
[ ] Sudden hot flashes
[ ] Spontaneous sweating
[ ] Shortness of breath and/or heart palpitations
[ ] Unpredictable vaginal bleeding
[ ] Difficulty holding urine
[ ] Difficulty sleeping
[ ] Mental fogginess
[ ] Vaginal pain and/or itching
[ ] Thin, scant white vaginal discharge
[ ] Low back and/or hip pain
[ ] Breast tenderness, pain or tingling, prickling sensation
[ ] Easy bruising, loss of skin tone
[ ] Thinning armpit and pubic hair
[ ] Stopped menstruating
[ ] Breasts beginning to shrink, sag
[ ] Abnormal growth of hair above lip
If you checked more than 3 boxes, you may be experiencing hormonal imbalance.
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