Female Hormone Questionnaire

Please carefully consider the symptoms listed below, and check only the those you experience regularly.

SYMPTOMS Yes
1. Do you have premenstrual syndrome?
2. Do you have monthly weight fluctuation?
3. Do you have edema, swelling, puffiness, or water retention?
4. Are you bloated?
5. Do you have headaches?
6. Do you have mood swings?
7. Do you have tender, enlarged breasts??
8. Do you have a poor mood?
9. Are you unable to cope with ordinary demands?
10. Do you have backaches, joint, or muscle pain?
11. Do you have premenstrual food cravings (especially sugar or salt)?
12. Do you have irregular cycles, heavy bleeding, or light bleeding?
13. Are you infertile?
14. Do you use birth control pills or other hormones?
15. Do you have premenstrual migraines?
16. Do you have breast cysts or lumps or fibrocystic breasts?
17. Do you have a family history of breast, ovarian, or uterine cancer?
18. Do you have a family history of uterine fibroids?
19. Do you have peri- or menopausal symptoms?
20. Do you have hot flashes?
21. Do you feel anxious?
22. Do you have night sweats?
23. Do you have insomnia?
24. Have you lost your sex drive?
25. Do you have dry skin, hair, and/or vagina?
26. Do you have heart palpitations?
27. Do you have trouble with memory or concentration?
28. Do you have bloating or weight gain around the middle?
29. Do you have facial hair?
30. Have you been exposed to pesticides or heavy metals (in food, water, air)?