HORMONE QUESTIONNAIRE
QUESTION 1
Are you menopausal (you’ve gone 1 whole year without a menstrual period)?
YES NO
QUESTION 2
Do you sleep well (you get enough sleep, you feel refreshed after you sleep, and you feel well-rested overall)?
YES NO
QUESTION 3
Do you suffer from any mood-related symptoms (PMS, crankiness, overly angry or reactive)?
YES NO
QUESTION 4a
Do you have temperature-related symptoms (hot flashes, night sweats)?
YES NO
QUESTION 4b
Do you have vaginal dryness, frequent urinary tract infections, or pain with sex?
YES NO
QUESTION 5
Is your level of sex drive (thoughts about sex and desire for sex) and ability to achieve orgasm satisfactory to you?
YES NO
QUESTION 6
Do you have unexplained abdominal weight gain?
YES NO
QUESTION 7
Are you satisfied with your overall feeling of well-being (energy level, confidence, physical tone, “mojo”)?
YES NO
QUESTION 8
Have you had general lab work in the past 6 months (check Vitamin D level, blood sugar, thyroid and cholesterol panels)?
YES NO
