Female Hormone Questionnaire Name* First Last PhoneEmail SymptomsDecline in Energy*NeverMildModerateSevereMemory Loss (forgetfulness)*NeverMildModerateSevereMental Confusion (feeling in a mental fog)*NeverMildModerateSevereSleep Problems (difficulty falling; staying asleep; waking up tired)*NeverMildModerateSevereDecrease sex drive/libido (decrease sexual drive)*NeverMildModerateSevereJoin pain*NeverMildModerateSevereFacial hair*NeverMildModerateSevereAcne*NeverMildModerateSevereDifficulty to climax sexually*NeverMildModerateSevereDepressive Mood (feeling down; sad; lack of drive)*NeverMildModerateSevereAnxiety (easily overwhelmed)*NeverMildModerateSevereMood Changes / Irritability*NeverMildModerateSevereHot flashes*NeverMildModerateSevereNight sweats*NeverMildModerateSevereVaginal dryness*NeverMildModerateSevereBloating*NeverMildModerateSevereBreast Tenderness*NeverMildModerateSevereMigraine/severe headaches*NeverMildModerateSevereHair is falling out (All over or in clumps)*NeverMildModerateSevereDry/wrinkled skin/brittle nails*NeverMildModerateSevereCold All the Time/Cold Hands/ Cold Feet*NeverMildModerateSevereWeight Gain/Difficulty Losing Weight*NeverMildModerateSevereSwelling all over body*NeverMildModerateSevereLow Energy (Need caffeine to “get going” in Morning)*NeverMildModerateSevereConstipation*NeverMildModerateSevereMenstrual Flow*HysterectomyMenopauseVery HeavyHeacyModerateLightMenstrual Regularity*Very IrregularSometimes IrregularMostly IrregularVery RegularOther symptoms that concern youFamily HistoryHeart Disease*YesNoDiabetes*YesNoOsteoporosis*YesNoAlzheimer’s Disease*YesNo
