Female Hormonal Questionnaire
Category 1.2: For those with ovaries and uterus.

Heavier than Normal Periods with Clotting

Please put a check next to any symptoms you experience during one month’s cycle.

Physical
Chronic fatigue
Exhaustion
Headaches
Migraines
Heart races or palpitates
Shortness of breath
Dizzy spells
Midriff weight gain
Water retention
Pressure in head, eyes, forehead
Pressure in the sinuses
Feeling hotter than others in the room
Hot flashes
Tight muscles in head, neck and shoulders
Low thyroid
Facial hair growth
Scalp hair loss
Hair growth in unwanted places
Pimple or acne on the face or body
Tender or painful breasts
Cystic breasts
Sexual
Decreasing sexual desire
Decreased sensitivity in erogenous zones
Irritating when touched in erogenous zones
Decreased ability to climax
No sexual desire
Inability to climax
Orgasm headache
Physical
Breast lumps or tumors
Poly cystic ovaries
Endometriosis
Uterine fibroids
Vaginal infections
Bladder infections
High blood pressure
Changes in eyesight
Dry eyes
Lowered immune function
Sinus infections
Nervous system disorders
Auto immune disorders
Lupus
Cervical thickening
Irregular PAP smear
Breast cancer
Cervical cancer
Uterine cancer
Vaginal cancer
Vulva cancer
Sleep
Trouble falling asleep
Insomnia
Restless sleep
Trouble staying asleep
Waking too early
Excessive dreaming
Nightmares
Getting up one or more times to urinate
Emotional
Anxiety
Excessive worry or fixed attention
Panic attack
Nervousness
Depression
Feeling sad or close to tears
Crying spells
Suicidal thoughts
Postpartum depression
Abnormal irritability to rage
Mood swings
Mental
Mental fog
Mental confusion
Poor concentration
Forgetfulness
Short term memory loss
Menstrual
Less than 28 days between periods
Periods more than 7 days
Heavy flow
Flooding
Clotting
Spotting between periods
Breakthrough bleeding
Thickened, brownish colored flow
Painful cramps
Painful ovulation
Please also fill in the form below for personal support and also so we can answer any of your questions.
*Name:
*Email:
*Phone:
*Age: *Weight: *Height:

* indicates a Required filed.