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PART 1 Do you have or have you experienced in the last 6 months?
*
A feeling that you're constantly racing from one task to the next
Feeling wired, but tired
A struggle calming down before bed time, or a second wind that keeps you up late
Difficulty falling asleep or disrupted sleep
A feeling of anxiety or nervousness about things beyond your control
A quickness to feel anger, rage (including frequent screaming or yelling?)
Memory lapses or feeling distracted, especially under duress
Sugar cravings (often after meals eg chocolate)
Increased abdominal circumference (abdominal fat, not just bloating)
Skin conditions eg eczema or thin skin
Bone loss (eg osteoporosis)
High blood pressure or rapid heart rate unrelated to normal events
High blood sugar symptomised by shaking between meals or being hangry)
Indigestion, ulcers, or gastric reflux
More difficulty recovering from injury than in the past
Unexplained pink/purple stretch marks on the stomach or back
Irregular menstrual cycles
Decreased fertility
None of the above
This questionnaire has been adapted from the AMAZING book by Sara Gottfried - The Hormone Cure. If you are serious about feeling better I strongly suggest that you invest in this book!
PART 2 Do you have or have you experienced in the last 6 months?
*
Fatigue or burnout (do you rely on caffeine OR fall asleep whilst watching a movie?)
Loss of stamina, particularly in the afternoon from 2-5pm
An atypical addiction to a negative point of view
Crying jags for no reason
Decreased problem solving ability
Feeling stressed most of the time (things seem harder than before and you have trouble coping)
Insomnia or difficulty staying asleep, especially between 1-4am
Low blood pressure
Postural hypotension (feeling dizzy when you go from sitting to standing)
Difficulty fighting infection, difficulty recovering from illness and difficulty healing wounds
Asthma, bronchitis, chronic cough, allergies
Low or unstable blood sugar
Salt cravings
Excess sweating
Nausea, vomiting, diarrhoea (or loose stools alternating with constipation)
Muscle weakness, especially around the knee, muscle or joint pain
Hemorrhoids or varicose veins
Your blood pools easily (easy to bruise)
A thyroid problem that has been treated, you feel better and suddenly you feel palpitations or have rapid or irregular heart beats
None of the above
PART3 Do you have or have you experienced in the last 6 months?
*
Agitation or PMS
Cyclical headaches (menstrual migraines)
Painful or swollen breasts
Irregular menstrual cycles
Heavy or painful periods (eg having to use ibuprofen to function)
Bloating, particuarly in the ankles and belly (are you gaining fluid weight before your period)
Ovarian cysts, breast cysts, endometrial cysts (polps)
Easily disrupted sleep
Itchy or restless legs, especially at night
Increased clumsiness or poor coordination
Infertility or subfertility
Miscarriage in first trimester
None of the above
PART 4 Do you have or have you experienced in the last 6 months?
*
Bloating, puffiness or water retention
Abnormal pap smears
Heavy bleeding or postmenopausal bleeding
Rapid weight gain particularly in the hips/bum
Increased bar cup size or breast tenderness
Fibroids
Endometriosis or painful periods
Mood swings, PMS, depression, irritatbility
Weepiness, sometimes over silly things
Mini breakdowns, anxiety
Migraines or other headaches
Insomnia
Brain fog
Red flush on face or rosacea
Gallbladder problems (or removal)
None of the above
If you have ticked some of these symptoms before in other sections please don't disregard them here, the symptoms are grouped together for a reason and some will cross over
PART 5 Do you have or have you experienced in the last 6 months?
*
Poor memory (walking into a room and forgetting why you were there)
Emotional fragility, especially compared to how you felt 10 years ago
Depression, perhaps with anxiety or lethargy
Wrinkles
Night sweats or hot flushes
Trouble sleeping, waking up in the middle of the night
A leaky or over active bladder
Bladder infections
Droopy breasts or lessening volume
Sun damage more obvious, glaring off your face chest and shoulders
Achy joints
Recent injuries, particularly to wrist, shoulder, lower back or knees
Loss of interest in exercise
Bone loss
Vaginal dryness, irritation or loss of feeling (like a dullness to your orgasm)
Lack of fluids elsewhere (dry eyes, dry skin, dry clitoris)
Low libido
Painful sex
None of the above
PART 6 Do you have or have you experienced in the last 6 months?
*
Excess hair on face chest or arms
Acne
Greasy skin or hair
Thinning hair on your head
Discolouration or armpits (darker and thicker than normal skin)
Skin tags (particularly around the bra strap, neck and on upper torso)
Hyperglycemia or hypoglycemia (unstable blood sugar)
Reactivity and/or irritability or excessively aggressive or authoritarian episodes
Depression, anxiety
Menstrual cycles occurring more than every 35 days
Ovarian cysts
Midcycle pain
Infertility or subfertility
Polycystic ovarian syndrome
None of the above
PART 7 Do you have or have you experienced in the last 6 months?
*
Hair loss including the outer third of tour eyebrows and/or eyelashes
Dry skin
Dry straw like hair that tangles easily
Thin brittle fingernails
Fluid retention or swollen ankles
An additional few pounds in weight that you just cant lose
High cholesterol
Bowel movements less often than once per day or a feeling of not totally evacuating
Recurrent headaches
Decreased sweating
Muscle or joint aches or poor muscle tone
Tingling in hands or feet
Cold hands or feet
A sensitivity to cold
Slow speech, perhaps with hoarse or halting voice
A slow heart rate or bracychardia
Lethargy (hard to move)
Fatigue particularly in the morning
Slow brain, slow thoughts, difficulty concentrating
Sluggish reflexes
Low sex drive and don't know why
Depression or moodiness
A prescription for antidepressants but still not feeling well
Heavy periods or other menstrual problems
Infertility or miscarriage
An enlarged thyroid/goiter, difficulty swallowing, enlarged tongue
A family history of thyroid problems
None of the above
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