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Hormone Assessment

Female Hormone Self-Assessment Test

YOU CAN IMPROVE YOUR HORMONAL HEALTH
Check any of the following statements that apply to you.

Date:
First Name:
Last Name:
Age:
Email:
Have you had a hysterectomy? Yes No
Do You...
	Have a history of antibiotic use
	Continuously use prescription medication
	Take synthetic hormones in topical cream, patch or orally
	Experience difficulty sleeping
	Experience mood swings
	Experience hot flashes
	Experience low libido
	Drink more than one glass of alcohol weekly
	Drink caffeine daily
	Experience Exhaustion
	Experience irregular menstrual cycle
	Experience infertility
	Experience frequent urination

Menstrual or Menopause Concern Ovarian Dysfunction.......Do You Have?
	Vaginal dryness, pain
	Painful intercourse
	Engorged breasts
	Milk production (not nursing)
	Lack of interest in sex
	Blurred vision
	Headache
	Acne and/or oily skin
	Aggressive feelings
	Overwhelming sexual urges
	Absence of menstrual flow for six or more months
	Occasionally skip periods
	Menstruation began after 16 years old
	Breasts shrinking
	Thinning pubic and armpit hair
	Unable to get pregnant
	Miscarriage
	Excess facial hair
	Poor sense of smell
	Monthly abdominal pain without bleeding
	Menstrual type pain between menses
	Irregular time intervals between periods
	Menstrual cycles greater than 32 days
	Menstrual cycles less than 24 days
	Vaginal bleeding between periods
	Pain during periods is getting progressively worse
	Pain, cramps

Premenstrual Syndrome (3 days to 2 weeks prior to menstruation)
Do You Have...
	Premenstrual tension
	Painful menses (cramping etc.)
	Menstruation excessive or prolonged
	Painful/tender breasts
	Menstruate too frequently
	Acne, worse at menses
	Depressed feelings before menstruation
	Vaginal discharge
	Menses scanty or missed
	Hysterectomy/ovaries removed
	Depression
	Insomnia
	Abdominal bloating
	Breast tenderness, swelling
	Depressed, irritable, nervous
	Easy to anger, resentful
	Easily overwhelmed
	Nausea and/or vomiting
	Diarrhea or constipation
	Headache
	Food cravings, binge eating
	Back pain
	Feel faint
	Clumsiness
	Forgetful
	Weight gain-water
	Suicidal

Dysplasia / Fibrocystic Syndrome
Do You Have...
	Lumps are painful, tender
	Clear, gray or yellow vaginal discharge
	Vaginal bleeding after sex or between periods
	Burning or itching or external genitalia
	Urgent, painful urination
	Lower abdominal or back pain
	Heavy, watery and bloody vaginal discharge
	Heavy menstrual flow
	Pelvic cramps
	Thin, scant white vaginal discharge
	Greenish yellow or offensive discharge
	Cheesy white discharge
	Breast lumps or swelling
	Lumps hurt just before period
	Swelling under armpit
	Change in breast size, shape
	White or slightly bloody vaginal discharge, one week prior to period
	Current diagnosis of fibrocystic breast disease

Menopause
Do You Have...
	Irregular menstrual cycle
	Menstruation excessive or prolonged
	Menstruation too frequent
	Acne, worse at menses
	Menses scanty or missed
	Hysterectomy / ovaries removed
	Dry skin, hair, vagina
	Lack of interest in sex
	Mood swings, irritable
	Depression, anxiety, nervousness
	Craving for sweets, binge eating
	Headaches or dizziness
	Painful intercourse
	Sudden hot flashes
	Spontaneous sweating
	Shortness of breath and/or heart palpitations
	Unpredictable vaginal bleeding
	Difficulty holding urine
	Difficulty sleeping
	Mental fogginess
	Vaginal pain and/or itching
	Thin, scant white vaginal discharge
	Low back and/or hip pain
	Breast tenderness, pain or tingling, prickling sensation
	Easy bruising, loss of skin tone
	Thinning armpit and pubic hair
	Stopped menstruating
	Breasts beginning to shrink, sag
	Abnormal growth of hair above lip

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