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WOMEN’S HORMONE QUESTIONAIRE
Women Hormone Survey
First Name
Last Name
Email
Phone Number
Age
Uterus:
Yes
No
Ovaries:
Yes
No
Sleep Disturbance
Insomnia:
Not a problem
Sometimes
Frequent
Disruption:
Not a problem
Sometimes
Frequent
Cognitive Changes
Focus:
No changes
Sometimes
Frequent
Forgetful:
No changes
Sometimes
Frequent
Foggy:
No changes
Sometimes
Frequent
Temperature Change
Cold Intolerance:
Never
Occasional
Frequent
Often
Hot Flashes:
Never
Occasional
Frequent
Often
Sweats:
Never
Occasional
Frequent
Often
Headaches
Frequency:
Not a problem
Sometimes
Often
Severity:
Not a problem
Slight pain
Severe pain
Mood Change
Motivation:
No change
Decreased motivation
No motivation
Depression:
Never
Situational
Often
Always
Irritability:
Never
Situational
Often
Always
Tearfulness:
Never
Situational
Often
Always
Anxiety:
Never
Situational
Often
Always
Menstrual Irregularity
Clots:
No clots
Small dime size clots
Large quarter size clots / greater
Breakthrough Bleeding:
None
Occasional spotting
Spotting Often
Change in Cycle:
No change
Heaver than usual
Lighter than usual
Duration:
None
1-2 Days
3-5 Days
5+ Days
Fatigue/Decreased Energy
Fatigue/Decreased Energy:
No change
Sometimes
Always
Weight Gain
Weight Gain:
Yes
No
Abdominal Mass Increase:
Yes
No
Dieting Results:
No dieting
Some results
No results
Sexual Function
Decreased Libido:
No change
Decreased
No libido
Achieving Orgasm:
No change
More difficult
Cannot achieve
Painful Intercourse:
No pain
Sometimes pain
Always painful
Vaginal Dryness:
No dryness
Sometimes dry
Always dry
Breast Tenderness
Breast Tenderness:
No tenderness
Sometimes tender
No sensitivity
Bladder
Frequency/Urgency:
Never
Occasional
Often
Always
Leaking/Stress Incontinence:
Never
Occasional
Often
Always
Hair/Skin
Hair Dryness:
No
Some
Very dry
Hair Brittleness:
No
Notice difference
Frequent breaking
Hair Loss:
No loss
Some loss
Large amount
Skin Dryness:
No
Some
Very dry
Skin Elasticity:
Skin tight
Starting to sag
Very saggy
Muscle Loss
Mass:
No change
Slight decrease
Noticeable decrease
Tone:
No change
Slight change
Noticeable change
Strength:
No change
Slight change
Noticeable change
Cellulite:
No change
Slight change
Noticeable change
Chronic Pain
Stiffness:
Yes
No
Decreased Joint Mobility:
Yes
No
Sore Muscles:
Yes
No
Achiness:
Yes
No
Arthritis:
Yes
No
Heartburn
Heartburn:
Yes
No
Constipation
Constipation:
Yes
No
Cardiac Changes
Shortness of Breath:
Yes
No
Chest Pain:
Yes
No
Flutters/Palpitations:
Yes
No
Decreased Exercise Tolerance:
Yes
No
Diagnosed Heart Condition:
Yes
No
Body Oder Changes
Body Oder Changes (need to change deodorant frequently):
Yes
No
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