Hormone Questionnaire
Hormone Questionnaire
Please check all that apply to you.
Part A: High Cortisol
Do you often feel like you're constantly rushing from one task to another?
Do you feel both energized and exhausted at the same time?
Do you struggle to wind down before bed, or get a burst of energy that keeps you up late?
Is it hard for you to fall asleep or stay asleep through the night?
Do you experience anxiety or constant worry about things out of your control?
Are you quick to anger or find yourself frequently yelling or screaming?
Do you have trouble remembering things or staying focused, especially when stressed?
Do you crave sweets, especially chocolate, after meals?
Have you noticed your waistline increasing, with your abdomen measuring more than 35 inches?
Are you dealing with skin issues like eczema or thinning skin, both physically and emotionally?
Have you experienced bone loss, with terms like osteopenia or osteoporosis mentioned by your doctor?
Do you have high blood pressure or a rapid heartbeat not related to excitement?
Has your blood sugar been high, with terms like prediabetes, diabetes, or insulin resistance mentioned by your clinician?
Do you feel shaky between meals, indicating unstable blood sugar levels?
Do you suffer from indigestion, ulcers, or GERD (acid reflux)?
Are you finding it harder to recover from physical injuries than before?
Have you noticed unexplained pink or purple stretch marks on your belly or back?
Are your menstrual cycles irregular?
Have you experienced a decrease in fertility?
Part B: Low Cortisol
Feeling tired or burned out (you rely on caffeine for energy or fall asleep while reading or watching TV)?
Losing energy, especially in the afternoon between two and five?
Finding yourself unusually stuck in a negative mindset?
Experiencing sudden bouts of crying without a clear reason?
Struggling to solve problems or think clearly?
Feeling stressed most of the time, with everything seeming harder than it used to be and having a lower tolerance for stress?
Trouble sleeping or staying asleep, especially waking up between one and four in the morning?
Having low blood pressure (which can limit the oxygen your body, especially your brain, receives)?
Feeling lightheaded or dizzy when standing up too quickly (postural hypotension)?
Having a weak immune system (catching every cold or virus, particularly respiratory ones)?
Taking longer to recover from illness, surgery, or wounds?
Experiencing asthma, bronchitis, chronic cough, or allergies?
Dealing with low or unstable blood sugar levels?
Craving salty foods?
Sweating excessively?
Experiencing nausea, vomiting, diarrhea, or alternating between loose stools and constipation?
Feeling muscle weakness, particularly around the knees, or having muscle or joint pain?
Suffering from hemorrhoids or varicose veins?
Noticing that your blood pools easily or that you bruise easily?
Having a thyroid problem that was treated, feeling better, but then experiencing heart palpitations or irregular heartbeats (a sign of low cortisol combined with low thyroid function)?
Part C: Low Progesterone and Progesterone Resistance
Feeling agitated or experiencing PMS symptoms?
Having headaches that follow your menstrual cycle, especially hormonal migraines?
Dealing with painful or swollen breasts?
Irregular menstrual cycles, or noticing your cycles becoming more frequent as you get older?
Having heavy or painful periods (heavy means needing to change a super pad or tampon every two hours or less; painful means you need ibuprofen to function)?
Experiencing bloating, especially in your ankles and belly, or retaining fluid (gaining 3 to 5 pounds or more before your period)?
Suffering from ovarian, breast, or endometrial cysts (like polyps)?
Finding that your sleep is easily disturbed?
Experiencing itchy or restless legs, especially at night?
Noticing increased clumsiness or poor coordination?
Struggling with infertility or difficulty conceiving (you've been trying to get pregnant but haven't reached the official twelve-month mark, or six months if you're thirty-five or older)?
Having a miscarriage in the first trimester?
Part D: Excess Estrogen
Experiencing bloating, puffiness, or water retention?
Having abnormal Pap smears?
Heavy bleeding or bleeding after menopause?
Gaining weight quickly, especially around the hips and buttocks?
Noticing an increase in bra size or feeling breast tenderness?
Dealing with fibroids?
Suffering from endometriosis or painful periods (endometriosis occurs when the lining of the uterus grows outside of it, like on the ovaries or bowel, causing painful periods)?
Experiencing mood swings, PMS, depression, or irritability?
Feeling overly emotional or crying easily, even over small things?
Having mini breakdowns or anxiety?
Getting migraines or other headaches?
Struggling with insomnia?
Feeling mentally foggy or unfocused?
Noticing a red flush on your face (or having been diagnosed with rosacea)?
Having gallbladder problems or needing gallbladder removal?
Part E: Low Estrogen
Experiencing poor memory (you walk into a room and forget why or lose your train of thought mid-sentence)?
Feeling emotionally fragile, especially compared to how you felt ten years ago?
Feeling depressed, possibly with anxiety or low energy (or dealing with dysthymia, a low-grade depression lasting more than two weeks)?
Noticing that your favorite skin cream no longer works on wrinkles?
Experiencing night sweats or hot flashes?
Having trouble sleeping or waking up in the middle of the night?
Dealing with a leaky or overactive bladder?
Getting bladder infections?
Noticing your breasts becoming droopy or losing volume?
Seeing more obvious sun damage on your chest, face, and shoulders?
Feeling achy joints (sometimes feeling much older than you are)?
Suffering from recent injuries, especially to your wrists, shoulders, or lower back?
Losing interest in exercise?
Experiencing bone loss?
Dealing with vaginal dryness?
Having dry eyes or dry skin?
oticing a low libido (it’s been decreasing for a while, and now it’s half or less than what it used to be)?
Finding sex painful?
Part F: Excess Androgens
Excess hair growth on your face, chest, or arms?
Struggling with acne?
Greasy skin or hair?
Thinning hair on your head (which feels unfair if you're also dealing with extra hair growth elsewhere)?
Darker and thicker skin in your armpits?
Skin tags, especially around your neck and upper torso? (These are small, flesh-colored growths caused by friction, often around bra straps, and are usually harmless.)
Unstable blood sugar levels, whether high (hyperglycemia) or low (hypoglycemia)?
Being overly reactive, irritable, or having episodes of excessive aggression (like road rage)?
Feeling depressed?
Experiencing anxiety?
Menstrual cycles that are more than thirty-five days apart?
Ovarian cysts?
Mid-cycle pain?
Struggling with infertility or subfertility?
Diagnosed with polycystic ovary syndrome (PCOS)?
Part G: Low Thyroid Function
Hair loss, including thinning of the outer third of your eyebrows or eyelashes?
Dry skin?
Dry, straw-like hair that tangles easily?
Thin, brittle fingernails?
Swelling or fluid retention, especially in your ankles?
Gaining a few extra pounds, or more, that you can't seem to lose?
High cholesterol?
Having bowel movements less often than once a day, or feeling like you don't completely empty your bowels?
Frequent headaches?
Decreased sweating?
Muscle or joint aches, or feeling like your muscle tone has weakened?
Tingling in your hands or feet?
Cold hands and feet? Feeling intolerant to cold or heat?
Sensitivity to cold (you feel colder than others and often wear extra layers)?
Speaking more slowly, possibly with a hoarse or halting voice?
A slow heart rate, or bradycardia (fewer than 60 beats per minute, and not because you're an elite athlete)?
Feeling lethargic (like you're moving through molasses)?
Fatigue, especially in the morning?
Slow thoughts or difficulty concentrating?
Sluggish reflexes, slower reaction times, or feeling a bit apathetic?
Low sex drive, and you're unsure why?
Feeling depressed or moody (life doesn't seem as bright as it used to)?
Taking an antidepressant but still not feeling like yourself?
Heavy periods or other menstrual issues?
Infertility, miscarriage, or preterm birth?
An enlarged thyroid or goiter? Trouble swallowing? Enlarged tongue?
A family history of thyroid problems?
Is there anything else you'd like to elaborate on?
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