Hormone Balance Questionnaire

Hormone Balance Questionnaire

Read carefully through the list of symptoms, put a checkmark next to any you experience, and add up the checks within each grouping. Note that each part should be answered separately.

Just like the Venn diagram of overlapping circles, you may have symptoms that fit into more than one part (such as infertility and mood issues). In other words, some of your answers may be repeated – but usually one or two areas will stand out as your key hormonal challenges.

Don’t fret! At the end, we’ll work through what your answers mean.

Part A: Do you or have you experienced in the past 6 months

Part B: Do you or have you experienced in the past 6 months

Part C: Do you or have you experienced in the past 6 months

Part D: Do you or have you experienced in the past 6 months

Part E: Do you or have you experienced in the past 6 months

Part F: Do you or have you experienced in the past 6 months

Part G: Do you or have you experienced in the past 6 months

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