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Complete the questionnaire below to help find out whether your current symptoms may be due to your hormones.
Developed by our experts, this questionnaire is often used by doctors as part of their assessment of a woman's symptoms and to monitor the results of treatment.
Hormone Questionnaire Your Name (required)
Your Email (required)
Contact Number
Date of Birth
Vasomotor (Adrenaline Surges)
Hot Flushes —Please choose an option—YesNo Night Sweats —Please choose an option—YesNo Panic Attacks —Please choose an option—YesNo Palpitations —Please choose an option—YesNo Poor Sleep —Please choose an option—YesNo Vivid dreams nightmares—Please choose an option—YesNo
Mood/Concentration/Psychological
Tiredness —Please choose an option—YesNo Loss of confidence —Please choose an option—YesNo Mood swings / Hypo and hyperactive—Please choose an option—YesNo Reduced memory —Please choose an option—YesNo Clumsy —Please choose an option—YesNo Depressed low feeling—Please choose an option—YesNo
Insulin resistance/glucose intolerance
Difficulty losing weight fluctuating weight —Please choose an option—YesNo Carbohydrate cravings/unusual hunger —Please choose an option—YesNo Facial Spots —Please choose an option—YesNo Increased facial body hair —Please choose an option—YesNo
Bladder/Vaginal/Menstrual Symptoms
Urinary urgency —Please choose an option—YesNo Vaginal dryness pain —Please choose an option—YesNo Lack of sexual interest performance —Please choose an option—YesNo Change of menstrual cycle —Please choose an option—YesNo
If you have any other symptoms please detail them below
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