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Hormone Questionnaire

Instructions: Please indicate with an (x), any of these symptoms that you may experience on a regular basis. Add an additional (p) if this is something you have experienced in the past.

There may be some repetition in various sections, please mark all that apply even if previously marked in another section. "Feel free to add anything you feel is important for Dr. Sandy to know in the Note sections of each page."

Patient Name: Date:

√ Section 1:

Inability to focus Feeling moody High blood pressure

Poor name or word recall Extra weight carried in the abdominal area

Cravings for sweet or starchy foods

Loss of creativity Gas, especially following consumption of carbs

Weight gain

Fuzzy thinking Extra weight carried in the buttocks

High Triglycerides

Difficulty learning Low blood sugar Feelings of agitation

Feeling jittery or anxious Intestinal bloating Increased fat storage

Depression Sleepiness following meals Extreme thirst or hunger

Feeling hungry after a meal Increased or frequent urination

Tingling sensations in hands or feet

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NOTES:


√ Section 2:

Low metabolism Decreased libido Anxiety

Weight gain Cold intolerance Weakness

Insulin resistance Difficulty losing weight Edema, esp. facial

Loss of outer 1/3 of eyebrow hair

Muscle cramps, frequent muscle aches

Increased or decreased blood pressure

Memory loss Abnormal menstrual cycles Uterine fibroids

Brittle, coarse or dry hair Elevated cholesterol Ringing in the ears

Morning headaches that wear off as day goes on

Low basal body temperature (resting body temps)

Decreased cognitive function, reduced initiative

Dry rough pale skin Fatigue Constipation

Irritability Aches & pains Slow wound healing

Brittle nails Cold hands or feet Thinning hair

Sleep disturbances Frequent colds & flu Breast or ovarian cysts

Depression Hair falls out easily Infertility


NOTES:


√ Section 3:

Increased metabolism Heat intolerance Breathlessness

Sleep disturbances Nervousness Hair loss

Excessive & inappropriate perspiration

Frequently feeling warmer than others.

Light or absent menstruation

Warm moist skin Insomnia Fast heart rate, palpitations

Weight loss without trying Fatigue Increased appetite

Increased bowel movements

Tremor of outstretched fingers

Bulging eyes

√ Section 4:

Please indicate with an (x), any of these symptoms that are troublesome now. Add an additional (p) if this is something you have experienced in the past.

Poor Immune Function Easily stressed Loss of libido

Memory and mood problems

Fatigue Bone Loss

Decreased stamina or muscle tone

Loss of head, armpit or pubic hair

√ Section 5:


Irritability Increased Body Hair Elevated Estrogen, or Testosterone

Increased Facial Hair Oily Skin Insomnia

Acne Unexplained anxiety Mood swings


√ Section 6:


Part 1:

Low-normal blood pressure Headache with stress or exertion

Difficulty getting started in the morning

Inflammation Unexplained body pains Crave sweets

Afternoon fatigue Afternoon Headache Weight loss

Weak nails Crave salty foods Frequent urination

Poor Appetite Low Blood Sugar Memory/Cognition Issues

Part 2:

Can’t fall asleep High anxiety, irritability Hair loss

High blood pressure Hypothyroidism High blood sugar

Poor or slow digestion Do best work late at night Increased hunger

Muscle weakness or bone loss

Blurred vision Skin conditions, eczema, acne

Male/Female hormone imbalance

Wake during the night with insomnia or “monkey-mind”

Thinning skin that bruises easily

Part 3:

General fatigue Allergic conditions Eating relieves fatigue

Depression Nervousness Low Libido

Infertility Gastric ulcer Frequent colds & flu

Susceptibility to infections /weak immune system

Sensitive to chemicals or smoke

Crave sweets, caffeine or cigarettes

Bone loss Insomnia Bloated feeling

Forgetful, brain fog Irritable before meals Autoimmune illness


High cholesterol or triglycerides

Shaky, nausea or lightheaded if meals are delayed


√ Section 7:


Hot flashes Heart palpitations Heavy menses

Polycystic Ovaries Fibrocystic breasts Painful Intercourse

Uterine fibroids Irritability Increased body or facial hair

History of Human Papilloma Virus (HPV)

Vaginal dryness, itchiness or burning pain

Bone loss

Mood swings Urinary incontinence Night sweats

Headaches Nipple discharge Endometriosis

Foggy thinking Weight gain Depressed mood

Fibrous Breast Tissue

√ Section 8:


Headaches Food cravings Weight gain

Swollen breasts Low sex drive Painful joints

Fuzzy thinking Cramps Inability to concentrate

Water retention Moodiness Acne

Depression Irritability or Anxiety Painful breasts

Insomnia PMS symptoms History of miscarriage


NOTES:


√ Section 9:


Hot flashes Night sweats Sleep disturbances

Headaches Anxiety Vaginal atrophy

Foggy thinking Mood swings Frequent yeast infections

Short-term memory loss Vaginal dryness or pain Heart palpitations

Low libido Dry, coarse or brittle hair Depression

Painful intercourse Dry Skin Bone loss

Frequent urinary tract infections

Shortness of breath Hair loss

√ Section 10:


Fatigue Headaches Fluid retention

Nervousness, anxiety, irritability

Heavy or irregular periods Uterine fibroids

Breast tenderness/ swelling Symptoms of low thyroid function

Cravings for sweets

Weight gain Loss of scalp hair Decreased libido

Fibrocystic breasts Sleep disturbances Mood swings


NOTES:


Please answer the following information:

Have you completed menopause. Yes or No? At what age?

Approximate age and date of Last Menstrual Period:

Average length of period:

Do you recall the pain level of the first 2-3 days (1-10):

Average length of cycle:

Menstrual flow: very heavy/heavy/medium/light:

Day of cycle blood was drawn on: (Day 1 is first day of menses; if in menopause disregard)

Number of Children: Ages:

History of gestational diabetes?

History of irregular cycles?

Endometriosis? Ovarian Cysts?

Uterine Polyps? Fibroids?

Did you experience PMS symptoms? Yes or No?

Please Describe:

Have you experienced symptoms of peri-menopause. Yes or No?

What age did the symptoms begin?

Do you still have your uterus and ovaries? Yes or No?

If not, the year and reason they were removed:


Continued:

Do you do self-breast exams? Yes or No.

How often?

History of bladder infections (UTIs)? Yes or No.

Frequency:

Date of last pap smear:

Result:

History of abnormal PAP Smear? Yes or No.

If yes, diagnosis and treatment:

History of Human Papilloma Virus (HPV): Yes or No.

Year diagnosed?

History or current use of Birth Control Pills? Yes or No.

If yes, how long were they used for?

Have you ever had pain, bleeding or discomfort with intercourse? Yes or No.

If yes, please elaborate

Have you ever used any acne medications? Yes or No.

If so, which medication?


Please Answer the Following Questions: Yes No

Weak fingernails—brittle, peeling or ridges?

I often have gas, bloating, or belching after meals.

I tend to feel full for quite some time after meals, or feel like food just sits in my stomach after meals.

I usually have bad breath.

I seem to be aging prematurely, even though I do everything right (eat well, exercise, avoid sun exposure, etc).

I have a strong appetite.

I often have constipation or diarrhea.

I have or have had iron deficiency anemia.

My hair is thin, brittle or weak.

I don’t digest food well. I often feel uncomfortable or unwell after eating.

My skin tends to be dry and/or weak.

I have a history of one or more of the following conditions: acne, eczema, rosacea, psoriasis, vitiligo, autoimmune disease, rheumatoid arthritis, bacterial overgrowth, candida, and food allergies.

I’ve lost so much hair, I seem to be balding.


Please describe your level (scale of 1 to 10) and major sources of stress (e.g., work, relationship, health):


Neurobehavioral Symptom Checklist

Patient Name: Date:

From time to time, everyone feels out of sorts, not themselves, nervous, depressed, irritable, or anxious. Illness and prescription medications can alter behavior, perception, and mood states as well. These questions are designed to assist you and your healthcare provider in identifying patterns of behavior and feelings that tend to affect the quality of your relationships with family and friends, performance at work, and your overall sense of well-being. By sharing this information, you participate as a partner in exploring some of the possible underlying causes of any emotional or mental discomfort you may be experiencing.

Directions:Please check the boxes that best describe your feelings and ability to function most of the time. When answering each question, consider the degree to which your daily life is affected.

√ 1. Over the last year, I have experienced:

Becoming forgetful Lapses in memory

Becoming less attentive Less interest in normal activities

Feeling less sharp Difficulty remembering people’s names

Difficulty making decisions Problems finding the right words to communicate

Difficulty solving routine problems Difficulty learning new things

Problems writing, reading, or organizing thoughts Difficulty following instructions

√ 2. I experience:

Lack of interest in normal activities Loss of energy

Oversleeping or sleepiness Sense of sadness for no apparent reason

Increased appetite, especially for carbohydrates Fatigue


Symptoms that usually get worse in the winter Weight gain or weight loss

Difficulty concentrating and processing information, especially in the afternoon

Diminished sexual desire

√ 3. I frequently:

Feel tense and have trouble relaxing Have trouble falling asleep or staying asleep

Women only: Get worse symptoms prior to getting my period

Sweat and have hot flashes in anticipation of events

Get crabby or grouchy Feel irritable or short tempered

Have trouble letting things go Get angry for no apparent reason

Have headaches and other aches and pains

√ 4. I often:

Feel overly active and compelled to do things, like being driven by a motor

Have difficulty relaxing and unwinding when I have time to myself

Misplace and have difficulty finding things Crave caffeine and stimulants to keep me going

Delay getting started when I have a task or work that requires a lot of thought

Get easily distracted by activity or noise around me

Have difficulty keeping my attention when doing boring and repetitive work

Fidget or squirm with my hands and feet when I have to sit down for a long time

Leave my seat in meetings or other situations in which I am expected to remain seated

Have problems remembering appointments or obligations

Have difficulty concentrating on what people say to me, even when they are speaking to me directly

Move around and kick in my sleep

√ 5. I experience:

Waking up frequently during the night with difficulty returning to sleep

Looking forward to catching up on my sleep on the weekends

Taking more than 30 minutes to fall asleep at night Stomach problems or nausea

Waking up repeatedly throughout the night Waking up groggy and not well rested


Preferring to go to sleep later than midnight and waking up late, after 10:00 A.M.

Preferring an early bedtime—going to sleep between 7 P.M. and 9 P.M. and waking up early, around 5:00 A.M.

Jet lag Difficulty turning off my thoughts when I lay down to sleep

NOTES:


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