Female Hormone Symptom Assessment

First Name

Last Name

Phone number

Your Email Address

Who is your referring Doctor?

This questionnaire has been designed to help identify which hormones may be contributing to your symptoms. It is important to answer all of the questions. When answering it is important to think about each of the areas and rate how significant the symptoms affects your health.The symptoms are rated as follows

The symptoms are rated as follows

• No Symptoms 

• Very Mild

• Mild

• Moderate

• Severe

• Very Severe

How would you rate your acne?NoneVery MildMildModerateSevereVery Severe

Please rate your anxiety/nervousness?NoneVery MildMildModerateSevereVery Severe

Please rate your apathy or lack of motivation?NoneVery MildMildModerateSevereVery Severe

Please rate your breast tenderness?NoneVery MildMildModerateSevereVery Severe

Please rate how Brittle your nails are?NoneVery MildMildModerateSevereVery Severe

Do you feel burnt out?NoneVery MildMildModerateSevereVery Severe

Do you suffer with chemical sensitivities?NoneVery MildMildModerateSevereVery Severe

Do you suffer with a cold body temperature?NoneVery MildMildModerateSevereVery Severe

Do you suffer with cold extremeties?NoneVery MildMildModerateSevereVery Severe

Do you feel confused?NoneVery MildMildModerateSevereVery Severe

Do you suffer with constipation?NoneVery MildMildModerateSevereVery Severe

Do you suffer with abdominal cramping?NoneVery MildMildModerateSevereVery Severe

Do you have cravings for sweet foods?NoneVery MildMildModerateSevereVery Severe

Do you have a reduced concentration?NoneVery MildMildModerateSevereVery Severe

Do you have a reduced sex drive?NoneVery MildMildModerateSevereVery Severe

Do you have reduced sexual sensations?NoneVery MildMildModerateSevereVery Severe

Do you have less stamina?NoneVery MildMildModerateSevereVery Severe

Is your voice deepening?NoneVery MildMildModerateSevereVery Severe

Do you have a depressed mood?NoneVery MildMildModerateSevereVery Severe

Do you have dry eyes?NoneVery MildMildModerateSevereVery Severe

Do you have dry skin or hair?NoneVery MildMildModerateSevereVery Severe

Do you suffer with fatigue?NoneVery MildMildModerateSevereVery Severe

Do you suffer with Fibrocystic Breasts which can make your breasts feel tender, lumpy or ropy?NoneVery MildMildModerateSevereVery Severe

Do you suffer fluid retention around your abdomen?NoneVery MildMildModerateSevereVery Severe

Do you suffer fluid retention around your extremeties (Legs, arms, hands,etc)?NoneVery MildMildModerateSevereVery Severe

Do you have foggy thinking?NoneVery MildMildModerateSevereVery Severe

Do you suffer with headaches?NoneVery MildMildModerateSevereVery Severe

Do you have heart palpitations?NoneVery MildMildModerateSevereVery Severe

Are your periods heavy or irregular? NoneVery MildMildModerateSevereVery Severe

Is your voice hoarse?NoneVery MildMildModerateSevereVery Severe

Do you have hot flashes?NoneVery MildMildModerateSevereVery Severe

Do you have hypoglycemia (Low blood sugar levels)NoneVery MildMildModerateSevereVery Severe

Do you have increased facial or body hair?NoneVery MildMildModerateSevereVery Severe

Are you experiencing hair loss?NoneVery MildMildModerateSevereVery Severe

Do you suffer irritability?NoneVery MildMildModerateSevereVery Severe

Do you suffer joint pains?NoneVery MildMildModerateSevereVery Severe

Do you suffer with low blood pressure?NoneVery MildMildModerateSevereVery Severe

Do you have problems with your memory?NoneVery MildMildModerateSevereVery Severe

Do you suffer mood swings?NoneVery MildMildModerateSevereVery Severe

Are you experiencing muscle pains?NoneVery MildMildModerateSevereVery Severe

Do you suffer with night sweats?NoneVery MildMildModerateSevereVery Severe

Do you experience numbness in your hands and feet?NoneVery MildMildModerateSevereVery Severe

Is sexual intercourse painful?NoneVery MildMildModerateSevereVery Severe

Do you suffer with premenstrual symptoms (mood swings, tender breasts, food cravings, fatigue, irritability and depression)?NoneVery MildMildModerateSevereVery Severe

Do you have cravings for salt?NoneVery MildMildModerateSevereVery Severe

Do you have sleep disturbances?NoneVery MildMildModerateSevereVery Severe

Do you have swollen eyes?NoneVery MildMildModerateSevereVery Severe

Are you teary and find you are crying more often?NoneVery MildMildModerateSevereVery Severe

Is your skin thinning?NoneVery MildMildModerateSevereVery Severe

Are you tired but wired , where you are exhausted or overly tired, but too anxious to sleep?NoneVery MildMildModerateSevereVery Severe

Do you experience urinary incontinence?NoneVery MildMildModerateSevereVery Severe

Do you notice vaginal dryness?NoneVery MildMildModerateSevereVery Severe

Are you ganinig weight around your waist?NoneVery MildMildModerateSevereVery Severe

Are you ganinig weight around your hips?NoneVery MildMildModerateSevereVery Severe

Your Hormone Score

If you have scored greater than 50% on the following hormone it is considered to be a significant factor in your restoration therapy.

High Estrogen Rating

IER1

IER2

Low Estrogen Rating

LER1

LER2

High Progesterone Rating

HPR1

IPR2

Low Progesterone Rating

LPR1

LPR2

High Testosterone Rating

HTR1

HTR2

Low Testosterone

LTR1

LTR2

High DHEA Rating

HDR1

HDR2

Low DHEA Rating

LDR1

LDR2

High Cortisol Rating

HCR1

HCR2

Low Cortisol Rating

LCR1

LCR2

High Insulin Rating

HIR1

HIR2

Low Thyroid Rating

LTHR1

LTHR2

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