hormone questionnaire

Please select YES/NO on all questions below.  Please answer to the best of your ability. 
1. name: *
2. date: *
part 1 - TD
3. has your muscle tone lessened? *
4. has your sex drive lessened? *
5. do you have decreased stamina and energy? *
part 2 - TE
6. do you have acne or excessively oily skin? *
7. do you have excessive body hair? *
8. has your behavior become more aggressive? *
part 3 - ED
9. are you experiencing hot flashes? *
10. are you experiencing night sweats? *
11. do you have mood swings? *
12. are you experiencing less mental clarity? *
13. do you have an increasingly poor memory? *
14. are you experiencing vaginal dryness/pain with intercourse? *
15. are you experiencing dry skin? *
16. do you have dry eyes? *
17. have you had any recent bladder infections? *
part 4 - EE
18. are you experiencing heavy bleeding? *
19. do you have difficult periods (excessive bleeding, clotting or cramping)? *
20. are your breasts tender around your period? *
21. are you experiencing pre- or post-menstrual headaches or migraines? *
22. do you have a decreased sex drive? *
23. do you have more irritability, anxiety or anger? *
part 5 - PD
24. are you having a harder time with PMS symptoms? *
25. are you experiencing heavy bleeding? *
26. do you have spotting between periods? *
27. are you retaining water or bloating? *
28. have you experienced recent weight gain? *
29. are you experiencing headaches and migraines? *
30. is your mood down or depressed? *
31. are you having increased nervousness? *
32. do you have a problem with endometriosis or fibroids? *
part 6 - PE
33. are you increasingly sleepy or drowsy? *
34. are you experiencing constipation? *
35. are you bloated? *
part 7 - TH
36. have you experienced recent weight gain? *
37. do you fatigue easily? *
38. are you experiencing ringing in your ears? *
39. are you sleepy during the day? *
40. are you sensitive to cold? *
41. do you have dry or scaly skin? *
42. are you experiencing constipation? *
43. do you feel you are mentally sluggish? *
44. is your hair coarse or falling out? *
45. do you have reduced motivation? *
46. do you have impaired hearing? *
47. do you have low blood pressure? *
part 8 - AF
48. have you lost weight without trying? *
49. do you have an intolerance to caffeine and/or sugar? *
50. are you having heart palpitations? *
51. are you having difficulty getting up in the morning? *
52. do you have continuing fatigue, not relieved by sleep and rest? *
53. are you experiencing lethargy, or lack of energy to do normal daily activities? *
54. are your thoughts less focused? *
55. do you have sugar cravings? *
56. do you have salt cravings? *
57. do you have fat cravings? *
58. do you have decreased tolerance for stress, noise, or disorder? *
59. do you have digestion problems? *
60. do you feel like you don't really wake up until 10:00 am? *
61. do you get a second wind in the evening and stay up late? *
62. are you lightheaded or dizzy when you stand up quickly? *
part 9 - L
63. are you increasingly sensitive to chemicals? *
64. do you have chronic constipation? *
65. do you have extreme fatigue? *
66. do you have heavy menstrual flow? *
67. do you have skin eruptions like acne, psoriasis or moles that are growing? *
Nutrition therapy is not intended as a diagnosis, treatment, prescription, or cure for any disease, mental or physical, and is not intended as a substitute for regular medical care.  This questionnaire is for informational purposes only.