Woman’s Hormone Questionnaire

Name:______________________Date: _____________  Age: _____________

Present Contraception:  ____ None ____ Pill  ____ IUD ____ Other

Hormonal imbalance may be related to many other secondary health concerns. Proper assessment and a treatment plan are important to optimize one’s health.
This subjective questionnaire will give your health care practitioner a quick summary of symptoms or signs that may be related to your hormonal balance.  It is not a substitute for professional medical advice from your health care provider.

If you experience PMS it is recommended to also fill out the PMS Questionnaire.

1. ____ Do you experience PMS?

2.  ____ Are your cycles irregular?

3.  ____Is your menses heavy or clotted or very dark in colour?

4. ____ Do you feel nervous or anxious?

5.  ____ Do you experience pain in the lower abdominal area?

6.  ____ Do you have increased facial hair growth?

7.  ____ Are you unable to loose weight despite a good diet and exercise?

8.  ____ Do you experience acne?

9.  ____ Do you have hot flashes?

10. ____ Do you experience bloating or swelling?

If you have answered yes to more than 2 of the above symptoms you may have a hormonal imbalance condition.

It is recommended to consult with your health care professional team.

To book an appointment.

PMS Questionnaire

Please rate the following symptoms according to the degree of severity, and indicate

when in your cycle you experience them.

( 1) Mild ( 2 )Moderate ( 3 ) Severe

( WB) Week before Week after ( WA) Other( O)

Add your points at the end and enter in the total score.

PMS-A ( hE/lP, luteal phase)

____ Anxiety 1 2 3

____ Irritability 1 2 3

____ Mood swings 1 2 3

____ Nervous tension 1 2 3

PMS-C ( GTT luteal phase)

____ Appetite increase 1 2 3

____ Headache 1 2 3

____ Fatigue 1 2 3

____ Dizziness/fainting 1 2 3

____ Palpitations 1 2 3

PMS-D (lE/hP)

____ Depression 1 2 3

____ Crying 1 2 3

____ Forgetfulness 1 2 3

____ Confusion 1 2 3

____ Insomnia 1 2 3

PMS-H (hW & A)

____ Fluid retention 1 2 3

____ Weight gain 1 2 3

____ Swollen extremities 1 2 3

____ Breast tenderness 1 2 3

____ Abdominal bloating 1 2 3

Other symptoms

____ Oily skin 1 2 3

____ Acne 1 2 3

____ Constipation 1 2 3

____ Diarrhea 1 2 3

____ Backache 1 2 3

____ Hives 1 2 3

____ Weakness 1 2 3

____ Pain radiates down thighs 1 2 3

During first two days of period

____ Menstrual cramps 1 2 3

____ Backache 1 2 3

If you have answered yes to more than 2 of the above symptoms you may have a hormonal imbalance .

It is recommended to consult with your health care professional team.

To book an appointment.