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.

First Name

Email Address

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

A feeling you’re constantly racing from one task to the next?

Feeling wired yet tired?

A struggle calming down before bedtime, or a second wind that keeps you up late?

Difficulty falling asleep or disrupted sleep?

A feeling of anxiety or nervousness – can’t stop worrying about things beyond your control?

A quickness to feel anger or rage – frequent screaming or yelling?

Memory lapses or feeling distracted, especially under stress?

Sugar cravings (you need “a little something” after each meal, usually of the chocolatey variety)?

Increased abdominal circumference, greater than 35 inches (the dreaded abdominal fat, or muffin top – not bloating)?

Skin conditions such as eczema or thin skin (sometimes physiologically and psychologically)?

High blood pressure or rapid heartbeat unrelated to those cute red shoes in the store window?

High blood sugar (maybe your doctor has mentioned the words prediabetes or even diabetes or insulin resistance)?

Shakiness between meals also known as blood sugar instability?

Indigestion, ulcers, or GERD (gastroesophageal reflux disease)?

More difficulty recovering from physical injury than in the past?

Unexplained pink or purple stretch marks on your belly or back?

Irregular menstrual cycle?

Decreased fertility?

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

Fatigue or burnout (you use caffeine to bolster your energy, or fall asleep while reading or watching a movie)?

Loss of stamina, particularly in the afternoon, from two to five?

An atypical addiction to a negative point of view?

Crying jags for no particular reason?

Decreased problem-solving ability?

Feeling stressed most of the time (everything seems harder than before, and you have trouble coping)?

Decreased stress tolerance?

Insomnia or difficulty staying asleep, especially between one and four in the morning?

Low blood pressure (not always a good thing, since your blood pressure determines the correct amount of oxygen to send through your body, especially into your brain)?

Postural hypotension (you stand up from lying down and feel dizzy)?

Difficulty fighting infection (you catch every virus you meet, particularly respiratory)? Difficulty recovering from illness or surgery or healing wounds?

Asthma? Bronchitis? Chronic cough? Allergies?

Low or unstable blood sugar?

Salt cravings?

Excess sweating?

Nausea, vomiting, diarrhoea? Or loose stool alternating with constipation?

Muscle weakness, especially around the knee? Muscle or joint paint?

Haemorrhoids or varicose veins?

Your blood seems to pool easily, or your skin bruises easily?

A thyroid problem that’s been treated, you feel better, and suddenly you feel palpitations or have rapid or irregular heartbeats (a sign of a low cortisol/low thyroid combo)?

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

Agitation or PMS?

Cyclical headaches (particularly menstrual or hormonal migraines)?

Painful and/or swollen breasts?

Irregular menstrual cycles, or cycles becoming more frequent as you age?

Heavy or painful periods (heavy: going through a super pad or tampon every two hours or less: painful: you can’t function without ibuprofen)?

Bloating, particularly in the ankles and belly, and/or fluid retention (in other words, you gain 3 to 5 pounds more before your period)?

Ovarian cysts, breast cysts, or endometrial cysts (polyps)?

Easily disrupted sleep?

Itchy or restless legs, especially at night?

Increased clumsiness or poor coordination?

Infertility or subfertility (you’ve been trying hard to conceive but haven’t hit the official twelve-month mark of no conception – six month if you’re thirty-five or older)?

Miscarriage on the first trimester?

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

Bloating, puffiness or water retention?

Abnormal pap smears?

Heavy bleeding or postmenopausal bleeding?

Rapid weight gain, particularly in the hips and butt?

Increased bra cup size or breast tenderness?

Fibroids?

Endometriosis, or painful periods? (endometriosis is when pieces of the uterine lining grow outside of the uterine cavity, such as on the ovaries or bowel, and cause painful periods.)

Mood swings, PMS, depression or just irritability?

Weepiness, sometimes over the most ridiculous things?

Mini breakdowns? Anxiety?

Migraines or other headaches?

Insomnia?

Brain fog?

A red flush on your face ( or a diagnosis of rosacea)?

Gallbladder problems (or removal)?

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

Poor memory (you walk into a room to do something, then wonder what it was, or draw blank midsentence)?

Emotional fragility, especially compared with how you felt ten years ago?

Depression, perhaps with anxiety or lethargy (or more commonly, dysthymia: low-grade depression that lasts more than two weeks)?

Wrinkles (your favourite skin cream no longer works miracles)?

Night sweats or hot flashes?

Trouble sleeping, waking up in the middle of the night?

A leaky or overactive bladder?

Bladder infections?

Droopy breasts, or breasts lessening in volume?

Sun damage more obvious, even glaring, on your chest, face and shoulders?

Achy joints (you feel positively geriatric at times)?

Recent injuries, particularly to wrists, shoulders, lower back or knees?

Loss of interest in exercise?

Bone loss?

Vaginal dryness, irritation, or loss of feeling (as if there were layers of blankets between you and the now-elusive toe-curling orgasm)?

Lack of juiciness elsewhere (dry eyes, dry skin, dry clitoris)?

Low libido (it’s been dwindling for a while, and now you realize it’s half or less than what it used to be)?

Painful sex?

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

Excess hair on your face, chest or arms?

Acne?

Greasy skin and/or hair?

Thinning head hair (which makes you question the justice of it all if you’re also experiencing excess hair growth elsewhere)?

Discoloration of your armpits (darker and thicker than your normal skin)?

Skin tags, especially on your neck and upper torso? (Skin tags are small, flesh-coloured growths on the skin surface, usually a few millimetres in size and smooth. They are usually noncancerous and develop from friction, such as around the bra straps. They don’t change or grow over time).

Hyperglycaemia or hypoglycaemia and/or unstable blood sugar?

Reactivity and/or irritability, or excessively aggressive or authoritarian episodes (also known as ‘roid rage’)?

Depression? Anxiety?

Menstrual cycles occurring more than thirty-five days?

Ovarian cysts?

Midcycle pain?

Infertility? Or subfertility?

Polycystic ovarian syndrome, PCOS?

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

Hair loss, including the outer third of your eyebrows and/or eyelashes?

Dry skin?

Dry, straw-like hair that tangles easily?

Thin, brittle finger nails?

Fluid retention or swollen ankles?

An additional few pounds, or 20, that you can’t just lose?

High cholesterol?

Bowel movements less often than once per day, or you feel you don’t completely evacuate?

Recurrent headaches?

Decreased sweating?

Muscle or joint aches or poor muscle tone (you became an old lady overnight)?

Tingling in your hands or feet?

Cold hands and feet? Cold intolerance? Heat intolerance?

A sensitivity to cold (you shiver more easily than others and are always wearing layers)?

Slow speech, perhaps 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)?

Lethargy (you feel like you’re moving through molasses)?

Fatigue, particularly in the morning?

Slow brain, slow thoughts? Difficulty concentrating?

Sluggish reflexes, diminished reaction time, even a bit of apathy?

Low sex drive, and you’re not sure why?

Depression or moodiness (the world is not as rosy as it used to be)?

A prescription for the latest antidepressant but you’re still not feeling like yourself?

Hormone Balance Questionnaire