Hormone Questionnaire

Vasomotor (Adrenaline Surges)

Hot flushes
NilMildModerateSevere Cyclical
Night sweats
NilMildModerateSevere Cyclical
Panic attacks
NilMildModerateSevere Cyclical
Palpitations
NilMildModerateSevere Cyclical
Poor sleep/sudden wakening
NilMildModerateSevere Cyclical
Vivid dreams/nightmares
NilMildModerateSevere Cyclical

Mood / Concentration / Psychological

Tiredness
NilMildModerateSevere Cyclical
Early morning / Mid-afternoon exhaustion
NilMildModerateSevere Cyclical
Mood swings / Hypo and hyper active
NilMildModerateSevere Cyclical
Aggressive / Short fuse
NilMildModerateSevere Cyclical
Depressed / Low feeling
NilMildModerateSevere Cyclical
Paranoid / Negative feelings
NilMildModerateSevere Cyclical
Loss of confidence
NilMildModerateSevere Cyclical
Reduced memory / Concentration / Attention deficit
NilMildModerateSevere Cyclical
Disorientated / Out of body feeling
NilMildModerateSevere Cyclical
Clumsy
NilMildModerateSevere Cyclical

Insulin resistance / Glucose intolerance

Central abdominal weight gain
NilMildModerateSevere Cyclical
Difficulty losing weight / Fluctuating weight
NilMildModerateSevere Cyclical
Carbohydrate cravings / Unusual hunger
NilMildModerateSevere Cyclical
Dizzy episodes
NilMildModerateSevere Cyclical
Facial spots
NilMildModerateSevere Cyclical
Increased facial hair
NilMildModerateSevere Cyclical
Increased body hair
NilMildModerateSevere Cyclical
Reduced scalp hair
NilMildModerateSevere Cyclical

Bladder / Vaginal / Menstrual Symptoms

Urinary frequency
NilMildModerateSevere Cyclical
Urinary urgency
NilMildModerateSevere Cyclical
Getting up at night to pass urine
NilMildModerateSevere Cyclical
Leaking on coughing / Straining
NilMildModerateSevere Cyclical
Vaginal dryness / pain
NilMildModerateSevere Cyclical
Lack of sexual interest / performance
NilMildModerateSevere Cyclical
Vaginal discharge
NilMildModerateSevere Cyclical
Change of menstrual cycle
NilMildModerateSevere Cyclical

Bowel Related Symptoms

Early morning / constant nausea
NilMildModerateSevere Cyclical
Bloating
NilMildModerateSevere Cyclical
Abdominal pain
NilMildModerateSevere Cyclical
Constipation / Irritable bowel
NilMildModerateSevere Cyclical

Connective Tissue / Collagen Symptoms associated with hormone loss

Early morning / constant joint pains
NilMildModerateSevere Cyclical
Dry, itchy eyes
NilMildModerateSevere Cyclical
Blurred vision / Runny eyes
NilMildModerateSevere Cyclical
Dry skin / Itchy skin / Brittle nails
NilMildModerateSevere Cyclical
Dry ears / Itchy ears / Ringing ears
NilMildModerateSevere Cyclical
Dry mouth / Mouth ulcers
NilMildModerateSevere Cyclical
Thirsty, burning mouth, metallic taste
NilMildModerateSevere Cyclical
Dry nose / Nose bleeds
NilMildModerateSevere Cyclical
Increased skin irritation / eczema / rashes
NilMildModerateSevere Cyclical

Airways / Breathing

Snoring / Sleep Apnoea
NilMildModerateSevere Cyclical
Shortness of breath
NilMildModerateSevere Cyclical
Persistent Cough
NilMildModerateSevere Cyclical

Additional Information

Please detail any current medication
(including non-prescription items)