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Hormone Questionnaire

Vasomotor (Adrenaline Surges)

 
Nil
Mild
Moderate
Severe
Cyclical
Hot flushes

Nil

Mild

Moderate

Severe

Cyclical
Night sweats

Nil

Mild

Moderate

Severe

Cyclical

Panic Attacks

Nil

Mild

Moderate

Severe

Cyclical

Palpitations

Nil

Mild

Moderate

Severe

Cyclical

Poor sleep/sudden wakening

Nil

Mild

Moderate

Severe

Cyclical

Vivid dreams/ nightmares

Nil

Mild

Moderate

Severe

Cyclical

Mood / Concentration / Psychological

 
Nil
Mild
Moderate
Severe
Cyclical
Tiredness

Nil

Mild

Moderate

Severe

Cyclical

Early morning / Mid-afternoon exhaustion

Nil

Mild

Moderate

Severe

Cyclical

Mood swings / Hypo and hyper active

Nil

Mild

Moderate

Severe

Cyclical

Aggressive / Short fuse

Nil

Mild

Moderate

Severe

Cyclical

Depressed / Low feeling

Nil

Mild

Moderate

Severe

Cyclical

Paranoid / Negative feelings

Nil

Mild

Moderate

Severe

Cyclical

Loss of confidence

Nil

Mild

Moderate

Severe

Cyclical

Reduced memory / Concentration / Attention deficit

Nil

Mild

Moderate

Severe

Cyclical

Disorientated / Out of body feeling

Nil

Mild

Moderate

Severe

Cyclical

Clumsy

Nil

Mild

Moderate

Severe

Cyclical

Insulin resistance / Glucose intolerance

 
Nil
Mild
Moderate
Severe
Cyclical
Central abdominal weight gain

Nil

Mild

Moderate

Severe

Cyclical

Difficulty losing weight / Fluctuating weight

Nil

Mild

Moderate

Severe

Cyclical

Carbohydrate cravings / Unusual hunger

Nil

Mild

Moderate

Severe

Cyclical

Dizzy episodes

Nil

Mild

Moderate

Severe

Cyclical

Facial spots

Nil

Mild

Moderate

Severe

Cyclical

Increased facial hair

Nil

Mild

Moderate

Severe

Cyclical

Increased body hair

Nil

Mild

Moderate

Severe

Cyclical

Reduced scalp hair

Nil

Mild

Moderate

Severe

Cyclical

Bladder / Vaginal / Menstrual Symptoms

 
Nil
Mild
Moderate
Severe
Cyclical
Urinary frequency

Nil

Mild

Moderate

Severe

Cyclical

Urinary urgency

Nil

Mild

Moderate

Severe

Cyclical

Getting up at night to pass urine

Nil

Mild

Moderate

Severe

Cyclical

Leaking on coughing / Straining

Nil

Mild

Moderate

Severe

Cyclical

Vaginal dryness / pain

Nil

Mild

Moderate

Severe

Cyclical

Lack of sexual interest / performance

Nil

Mild

Moderate

Severe

Cyclical

Vaginal discharge

Nil

Mild

Moderate

Severe

Cyclical

Change of menstrual cycle

Nil

Mild

Moderate

Severe

Cyclical

Bowel Related Symptoms

 
Nil
Mild
Moderate
Severe
Cyclical
Early morning / constant nausea

Nil

Mild

Moderate

Severe

Cyclical

Bloating

Nil

Mild

Moderate

Severe

Cyclical

Abdominal pain

Nil

Mild

Moderate

Severe

Cyclical

Constipation / Irritable bowel

Nil

Mild

Moderate

Severe

Cyclical

Connective Tissue / Collagen Symptoms associated with hormone loss

 
Nil
Mild
Moderate
Severe
Cyclical
Early morning / constant joint pains

Nil

Mild

Moderate

Severe

Cyclical

Dry, itchy eyes

Nil

Mild

Moderate

Severe

Cyclical

Blurred vision / Runny eyes

Nil

Mild

Moderate

Severe

Cyclical

Dry skin / Itchy skin / Brittle nails

Nil

Mild

Moderate

Severe

Cyclical

Dry ears / Itchy ears / Ringing ears

Nil

Mild

Moderate

Severe

Cyclical

Dry mouth / Mouth ulcers

Nil

Mild

Moderate

Severe

Cyclical

Thirsty, burning mouth, metallic taste

Nil

Mild

Moderate

Severe

Cyclical

Dry nose / Nose bleeds

Nil

Mild

Moderate

Severe

Cyclical

Increased skin irritation / eczema / rashes

Nil

Mild

Moderate

Severe

Cyclical

Airways / Breathing

 
Nil
Mild
Moderate
Severe
Cyclical
Snoring / Sleep Apnoea

Nil

Mild

Moderate

Severe

Cyclical

Shortness of breath

Nil

Mild

Moderate

Severe

Cyclical

Persistent Cough

Nil

Mild

Moderate

Severe

Cyclical

Additional Information

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