727-202-6807
ST. Petersburg Health & Wellness
222 2nd St. N., 33701
Female Hormone Questionnaire
Name: Click here to enter text. DOB: Click here to enter text. Date: Click here to enter text. Email: Click
here to enter text.
This questionnaire assesses your sex hormone function. Your sex hormones maintain youthful health
and prevent many diseases of aging. They are important for sexual characteristics, sex organ function
and sexual activity, but also for muscle, heart, brain, blood vessel and so many other functions. You can
tell this by many of the symptoms listed below. The more items checked below in a hormone category,
the greater the possibility you have a deficiency of that hormone. Certain symptoms/associations have a
higher likelihood than others.
Please mark the box of any that apply. Indicate the severity of each symptom you are experiencing
currently by typing a 1 – 5 (1=mild/5=severe) in the middle of the red line ( __ ). Some questions may
not sound as if they are requesting severity information or you may be unsure of the severity. In these
situations please enter your best guess. If the symptom is current, simply place a number in the
provided space. If it is a symptom that you have had in the past, please indicate severity & type the
word “past” in the space.
Hysterectomy ☐Yes ☐No
If Yes ☐Partial ☐Total
Date: Click here to enter text.
Menstruation
Regular Menses ☐Yes ☐No
Average # of days in cycle Click here to enter
text.
Blood Draw Day Click here to enter text. of cycle
Hormone Replacement ☐Yes ☐No
Name Click here to enter text.
Dose and Frequency Click here to enter text.
Name Click here to enter text.
Dose and Frequency Click here to enter text.
__Difficulty concentrating
__Decreased sex drive
__Hot flashes
__Night sweats
__Sleep disorders (hot flashes & night sweats)
__Vulvar/Vaginal shrinkage
__Vaginal itching
__Vaginal dryness
Lack of Estrogen
__Painful intercourse
__Fatigue (continuous)
__Dry skin
__Depression (continuous)
__Dry eyes
__Memory loss
__Dry mouth
__Lack of menstruation
__Muscle tenseness
__Scanty menstruation
__Anxiety
__Short or long menstrual cycle
__Irritability
__Recurrent bladder infections
__Aggressiveness
__Prolapse bladder, uterus, vagina, rectum
__Anger
__Cyclical Headaches/Migraine
__Rage
__Pale face & skin
__Lack of tolerance to stress (adrenalin blocks
progesterone receptors)
__Hollow face
__Sharp small wrinkles lips, eyes, hands, skin
__Small breasts
__Breast ptosis (drooping)
__Sensitivity to pain
__Increased expression of pain
__Insomnia
__Infertility
__Swollen belly
__Painful belly to touch
__Premature aging
__Bloating
__Osteopenia/Osteoporosis
__Premenstrual abdominal bloating
__Heart disease
_Increased abdominal fat
__Alzheimer's disease
__Weight gain
__Insulin resistance/ Type 2 DM
__PMS
__Abnormal cholesterol
__PMDD
__Increased blood pressure
__Cyclical Headache/Migraine
__Cataracts
__Cyclical Seizures
__Macular degeneration
__Premenstrual Headache/Migraine
__Colon cancer
__Premenstrual Moodiness/Mood swings
__Premenstrual Inability to concentrate
Lack of Progesterone
__Premenstrual Fuzzy ☐ thinking
__Nervous tenseness
__Premenstrual Depression
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__Large breasts
__Abnormal lipids
__Swollen breasts
__Increased blood pressure with stress
(adrenalin blocks progesterone receptors)
__Painful breasts
__Breast cysts (Fibrocystic breast)
__Breast cancer
__Low libido
__Food cravings – sweet
__Early menstruation
__Heavy menstruation
__Cramps
__Painful menstruation
__Pain on deep intercourse (Endometriosis)
__Endometriosis
__Endometrial hyperplasia
__Endometrial cancer
__Fibroids
__Enlarged uterus
__Ovarian cysts
__Reddish face & skin
__Swollen face & skin
__Swollen feet & ankles
__Infertility
__Preeclampsia
__Miscarriage
__Premature delivery
__Thinning hair
__Hypothyroid symptoms
Lack of Testosterone
__Nervous
__Irritable
__Ill at ease
__Lack of mental firmness
__Undecided, Hesitating
__Lack of self-confidence
__Lack of assertiveness
__Lack of authority
__Submissive
__Frequent complaints of illness
__Aging appearance
__Abdominal weight gain despite exercise
__Abdominal Obesity/Overweight
__Excess fat in breasts & hips
__Muscle laxity
__ Day & night sweats (head & upper chest
__Hot flashes
__Fatigue that increases with physical activity
__Lack of Energy
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__Tire easily
__Vaginal dryness
__Lack of interest in exercise
__ Painful intercourse
__Lack of endurance
__Lack or loss of sexual body scent
__Depression (continuous)
__Loss of height
__Negative attitude
__Slumped, fragile appearance
__Anxiety, fears
__Kyphosis, lordosis (excessive spine curvature)
__Excessive emotions with stress
__Pale skin
__Low resistance to stress
__Aging face
__Excessive sensitivity to difficulties
__Small wrinkles lips & eyes
__Reduced muscle strength
__Thin lips
__Reduced muscle mass
__Dry skin
__Muscle pains
__Thin skin
__Back pain
__Atrophic skin
__Sciatica
__Dry eyes
__Joint pain
__Decreased armpit, pubic & body hair
__Easy sun-burn
__Cellulite
__Urinary incontinence
__Varicose veins
__Decrease in sex drive
__Easy bruising
__Decreased nipple sensitivity
__Poor Concentration
__Decreased clitoral size & sensitivity
__Poor memory
__Decreased orgasm
__Joint disease
__Vaginal itching
__Osteoporosis
__Vaginal atrophy
__Atherosclerosis
Please email this completed form to SPHW@stpetehw.com. If you have any questions or wish to make
an appointment, please call 727-202-6807.
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