Female Hormone Questionnaire Name* First Last PhoneEmail SymptomsDecline in Energy* Never Mild Moderate Severe Memory Loss (forgetfulness)* Never Mild Moderate Severe Mental Confusion (feeling in a mental fog)* Never Mild Moderate Severe Sleep Problems (difficulty falling; staying asleep; waking up tired)* Never Mild Moderate Severe Decrease sex drive/libido (decrease sexual drive)* Never Mild Moderate Severe Join pain* Never Mild Moderate Severe Facial hair* Never Mild Moderate Severe Acne* Never Mild Moderate Severe Difficulty to climax sexually* Never Mild Moderate Severe Depressive Mood (feeling down; sad; lack of drive)* Never Mild Moderate Severe Anxiety (easily overwhelmed)* Never Mild Moderate Severe Mood Changes / Irritability* Never Mild Moderate Severe Hot flashes* Never Mild Moderate Severe Night sweats* Never Mild Moderate Severe Vaginal dryness* Never Mild Moderate Severe Bloating* Never Mild Moderate Severe Breast Tenderness* Never Mild Moderate Severe Migraine/severe headaches* Never Mild Moderate Severe Hair is falling out (All over or in clumps)* Never Mild Moderate Severe Dry/wrinkled skin/brittle nails* Never Mild Moderate Severe Cold All the Time/Cold Hands/ Cold Feet* Never Mild Moderate Severe Weight Gain/Difficulty Losing Weight* Never Mild Moderate Severe Swelling all over body* Never Mild Moderate Severe Low Energy (Need caffeine to “get going” in Morning)* Never Mild Moderate Severe Constipation* Never Mild Moderate Severe Menstrual Flow* Hysterectomy Menopause Very Heavy Heacy Moderate Light Menstrual Regularity* Very Irregular Sometimes Irregular Mostly Irregular Very Regular Other symptoms that concern youFamily HistoryHeart Disease* Yes No Diabetes* Yes No Osteoporosis* Yes No Alzheimer’s Disease* Yes No
