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• Have you had a hysterectomy?
• YesNo

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
• Excessfacial 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
• Painfulmenses (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
• Lackof interest in sex
• Mood swings, irritable
• Depression, anxiety, nervousness
• Craving for sweets, binge eating
• Headaches or dizziness
• Painful intercourse
• Sudden hot flashes
• Spontaneous sweating
• Shortnessof 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