Female Hormonal Questionnaire
Category 2.2: For those with ovaries but no uterus.

Ages 35-45

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
Breast lumps or tumors
Poly cystic ovaries
Endometriosis
Uterine fibroids
Mental
Mental fog
Mental confusion
Poor concentration
Forgetfulness
Short term memory loss
Physical
Vaginal infections
Bladder infections
Vaginal itching and/or burning
Vaginal tissue growing closed
Falling uterus
Bladder shrinkage
Urinary frequency
Urinary leakage (incontinence)
High blood pressure
Ringing in the ears
Changes in eyesight
Dry eyes
Lowered immune function
Bone loss
Osteopenia
Nervous system disorders
Auto immune disorders
Lupus
Cervical thickening
Irregular PAP smear
Breast cancer
Cervical cancer
Uterine cancer
Vaginal cancer
Vulva cancer
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
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
Sleep
Trouble falling asleep
Insomnia
Restless sleep
Trouble staying asleep
Waking too early
Excessive dreaming
Nightmares
Getting up one or more times to urinate
Please also fill in the form below for personal support and also so we can answer any of your questions.
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