Medical Questionnaire – Women hormonal assessment Last Name(Required) First Name(Required) Date of Birth(Required) DD slash MM slash YYYY Check all the appropriate responses felt in the last 6 months in all categories.Section 1 Do you feel like you’re constantly running from one task to the next? Feeling tired and feeling great at the same time? Do you find it difficult to calm down before bed, or do you have a second wind that keeps you awake? Do you have difficulty falling asleep or disturbed sleep? Do you have a feeling of anxiety or nervousness – you can’t help but worry about things that are out of your control? Do you get angry or angry quickly – to the point of frequent screaming or screaming? Do you have memory or distraction problems, especially when you’re under pressure or upset? Do you have frequent sugar cravings (you need a little something after each meal, e.g. chocolate)? Do you have an increase in abdominal circumference, greater than 88cm (the dreaded abdominal fat, or “muffin top”, without intestinal bloating)? Do you have skin conditions such as eczema or thin skin? Do you have bone loss (your doctor may be using scarier terms, such as osteopenia or osteoporosis)? Do you have high blood pressure or a rapid heartbeat unrelated to stressful or emotional events? Do you have high blood sugar (your clinician may have mentioned the words pre-diabetes or even diabetes or insulin resistance)? Do you have tremors and weakness between meals, also known as blood sugar instability? Do you have indigestion, ulcers or GERD (gastroesophageal reflux disease)? Are you having a harder time recovering from a physical injury than in the past? Do you have unexplained pink to purple stretch marks on your belly or back? Do you have irregular menstrual cycles? Do you have a decrease in fertility? Section 2 Do you feel tired or exhausted (do you consume caffeine to increase your energy or fall asleep while reading or watching a movie)? Do you have a loss of stamina, especially in the afternoon, of two to five hours? Do you have a rather negative perception of things? Do you have crying spells for no particular reason? Do you have a decreased ability to solve problems (less cognitive ability)? Do you feel stressed most of the time (everything seems harder than before and you find it difficult to cope with adversity? Do you have a decreased stress tolerance? Do you have insomnia or difficulty staying asleep, especially between one and four in the morning? Do you have low blood pressure (which isn’t always a good thing, as blood pressure determines the correct amount of oxygen to send into the body, especially the brain)? Do you have orthostatic hypotension (feeling dizzy easily after getting up from a lying position)? Are you having trouble fighting infections (you get all the viruses you come across, especially respiratory viruses)? Difficulty recovering from illness or surgery or healing wounds? Do you have asthma? Chronic bronchitis? Chronic cough? Seasonal allergies? Do you have low or unstable blood sugar levels? Do you have a craving for salt? Do you sweat excessively? Do you have nausea, vomiting or diarrhea? Loose stools alternating with constipation? Do you have muscle weakness, especially around the knees? Muscle or joint pain? Do you have hemorrhoids or varicose veins? Does your blood seem to pool easily or your skin gets easily covered in bruises? After a thyroid problem has been treated, you feel better a little later, and suddenly you feel palpitations or have a fast or irregular heartbeat? Section 3 Do you have restlessness, especially in the premenstrual period? Do you have cyclical headaches (especially menstrual or hormonal migraines)? Do you have sore and/or swollen breasts, especially before your period? Do you have irregular menstrual cycles or are they becoming more frequent as you age? Do you have heavy periods (clots, pad change/tampons <2h) or painful periods (you can't function without Advil)? Do you have water retention, especially in the ankles and stomach area (in other words, you gain 3 to 5 pounds or more before your period)? Do you have ovarian cysts, mammary cysts or endometrial cysts (polyps)? Do you have sleep that is easily disturbed? Do you have itchy legs or restless legs, especially at night? Have you noticed an increase in clumsiness or lack of coordination? Do you have infertility after 12 months of trying or subfertility (you tried to conceive but did not reach the official threshold of twelve months without conception – six months if you are thirty-five years old or older)? Have you ever had miscarriages in the first trimester? Section 4 Do you have bloating, puffiness or water retention? Have you ever had abnormal Pap smears? Do you have heavy bleeding or post-menopausal bleeding? Do you have rapid weight gain, especially in the hips and buttocks? Do you have an increase in bra cup size or constant breast tenderness? Do you have uterine fibroids? Do you have endometriosis or painful periods? (Endometriosis is characterized by the development of fragments of the uterine lining outside the uterine cavity, for example on the ovaries or intestines, and causes painful periods.) Do you have mood swings, premenstrual syndrome, depression or just irritability? Do you cry, sometimes over the most ridiculous things? Are you having panic attacks? Anxiety? Do you have migraines or other recurring headaches? Do you have insomnia? Do you have brain fog? Do you have redness on your face (or a diagnosis of rosacea)? Do you have gallbladder problems (or have you had an ablation in the past)? Section 5 Do you have a failing memory (you walk into a room to do something, then wonder what it was, or you have a memory lapse in the middle of the sentence)? Do you have an emotional fragility, especially compared to how you felt ten years ago? Do you have feelings of depression, possibly accompanied by anxiety or loss of motivation (or, more commonly, dysthymia: low-level depression that lasts more than two weeks? Do you have wrinkles (your favorite cream doesn’t work miracles anymore)? Do you have night sweats or hot flashes? Do you have trouble sleeping, do you wake up in the middle of the night? Do you have a leaky or overactive bladder? Do you have recurrent bladder infections? Do you have sagging or shrinking breasts? Is sun damage more obvious, if not blatant, on your chest, face, and shoulders? You have painful joints (you sometimes feel like an elderly person) Do you have recent injuries, especially to your wrists, shoulders, lower back or knees? Do you have a loss of interest in physical exercise? Have you been diagnosed with bone loss (the scarier names are osteopenia and osteoporosis)? Do you have vaginal dryness, irritation or loss of sensitivity? Do you have a lack of lubrication elsewhere (dry eyes, dry skin, dry clitoris)? Do you have a low libido (it’s been declining for a while and you realize it’s less than half or less than it used to be)? Are you having painful sex? Section 6 Do you have excess hair on your face, chest or arms? Do you need to go to the beautician to remove them? Do you have acne? Do you have oily skin and/or hair? Do you have thinning hair? Do you have discoloration in your armpits (darker and thicker than normal skin)? Do you have accordions? Do you have hyperglycemia or hypoglycemia and/or unstable blood sugar? Do you have psychological reactivity and/or irritability, or excessively aggressive or authoritarian episodes (borderline, “rage”)? Do you have depression? Anxiety? Do you have menstrual cycles occurring more than every thirty-five days? Do you have ovarian cysts? Do you have pain in the middle of your cycle? Do you have infertility? Do you have a diagnosis of “polycystic ovary syndrome”? Section 7 Are you losing your hair, including the outer third of the eyebrows and/or eyelashes? Do you have dry skin? Do you have dry, strawy hair that gets tangled easily? Do you have thin, brittle nails? Do you have water retention or swollen ankles? Do you have a few extra pounds that you can’t seem to lose? Do you have high cholesterol? Do you have bowel movements that are less frequent than once a day, or do you feel like you don’t pass them completely? Do you have recurring headaches? Do you have a decrease in sweating? Do you have muscle or joint pain or low muscle tone (you became an “old” woman overnight)? Do you have tingling in your hands or feet? Do you have cold hands and feet? Do you have a cold intolerance? Heat intolerant? Do you have a sensitivity to cold (you shiver more easily than others and always wear layers of clothing)? Do you have a slurred speech, perhaps a hoarse or gasping voice? Do you have a slow heart rate, or bradycardia (less than 60 beats per minute, and not because you are a high-performance athlete)? Do you feel lethargy (you feel like you’re walking through molasses and have little energy to get things done)? Do you feel tired, especially in the morning? Do you have a slow brain, slow thoughts, difficulty concentrating? Do you have lethargic relationship reflexes, reduced reaction time, or even apathy? Is your libido at half-mast and you’re not sure why? Do you have depression or a low mood (the world isn’t as rosy as it used to be)? Do you have a prescription for an antidepressant you’ve started but still don’t feel like yourself? Do you have heavy periods or other menstrual problems? Do you have infertility? Have you had a miscarriage or have you given birth to a child prematurely? Do you have an enlarged thyroid (goiter)? Difficulty swallowing? Do you have an enlarged tongue? Do you have a family history of thyroid disorders? CAPTCHA
