Hormone Symptom Questionnaire
Name
Name
First
Last
Gender
Difficulty Concentrating
Difficulty Concentrating
Increased Forgetfulness
Foggy Thinking
Tearful
Depressed
Mood Swings
Fluid Retention / Bloating
Stress
Anxious
Irritable
Nervous
Decreased Mental Sharpness
Morning Fatigue
Afternoon Fatigue
Evening Fatigue
Excessive Worry
Difficulty Falling Asleep
Difficulty Staying Asleep
Decreased Stamina
Diminished Motivation
Fibromyalgia
Ringing in Ears
Allergies
Headaches/Migraines
Dizzy Spells
Sugar Cravings
Addictive Behavior
Poor Impulse Control
Obsessive Behaviors (OCD)
Craving Food, Alcohol,
Tobacco or Other
Constipation
Goiter
Cold Body Temperature
Hoarseness
Hair Dry or Brittle
Nails Breaking or Brittle
Slow Pulse Rate
Rapid Heartbeat
Heart Fluttering/Palpitations
Incontinence
Hot Flashes
Night Sweats
Infertility Concerns
Acne
Scalp Hair Loss
Weight Gain-Hips
Weight Gain-Waist
High Cholesterol
Elevated Triglycerides
Decreased Libido
Decreased Muscle Mass
Decreased Flexibility
Burned Out Feeling
Sore Muscles
Increased Joint Pain
Neck or Back Pain
Bone Loss
Thinning Skin
Rapid Aging
Aches and Pains
IBS
Height (inches)
Weight (lbs)

Women Only

Vaginal Dryness
Irregular Periods
Uterine Fibroids
Tender Breasts
Fibrocystic Breasts
Increased Facial / Body Hair

Men Only

Decreased Urine Flow
Increased Urinary Urge
Prostate Problems
Decreased Erections