Women’s Hormone Balance Questionnaire Name *Email AddressPhoneInstructions: please put a 1 if the answer to the question is YESDo you or have you experienced in the past six months?PART A - HIGH CORTISOLA 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 duress?Sugar cravings (you need "a little something" after each meal, usually of the chocolate 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)?Bone loss (perhaps your doctor uses scarier terms, such as osteopenia or osteoporosis)?High blood pressure or rapid heartbeat?High blood sugar (maybe your clinician has mentioned the words prediabetes or even 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 to purple stretch marks on your belly or back?Irregular menstrual cycles?Decreased fertility?TOTALPART B - LOW CORTISOLFatigue 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, or diarrhea? Or loose stool alternating with constipation?Muscle weakness, especially around the knee? Muscle or joint pain?Hemorrhoids 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?)TOTALPART C - LOW PROGESTERONEAgitation 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 superpad 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 or 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 months if you're 35 or older)?Miscarriage in the first trimester?TOTALKeep going! You're halfway there! PART D - EXCESS ESTROGENBloating, 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)?TOTALPART E - LOW ESTROGENPoor memory (you walk into a room to do something, then wonder what it was, or draw a 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 favorite 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 orgasm)?Lack of juiciness elsewhere (dry eyes, dry skin, dry clitoris)?Low libido (it's been dwindling for while, and now you realize it's half or less that what it used to be)?Painful sex?TOTALPART F - EXCESS ANDROGENSExcess 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-colored growths on the skin surface, usually a few millimeters in size, and smooth. They are usually noncancerous and develop from friction, such as around bra straps. They do not change or grow over time.)Hyperglycemia or hypoglycemia and/or unstable blood sugar?Reactivity and/or irritability, or excessively aggressive or authoritarian episodes?Depression? Anxiety?Menstrual cycles occurring more than every thirty-five days?Ovarian cysts?Midcycle pain?Infertility? Or subfertility?Polycystic ovary syndrome?TOTALPART G - LOW THYROIDHair loss, including the outer third of your eyebrows and/or eyelashes?Dry skin?Dry, strawlike hair that tangles easily?Thin, brittle fingernails?Fluid retention or swollen ankles?An additional few pounds, or 20, that you just can't lose?High cholesterol?Bowel movements less often than once a 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?Heavy periods or other menstrual problems?Infertility or miscarriage? Preterm birth?An enlarged thyroid/goiter? Difficulty swallowing? Enlarged tongue?A family history of thyroid problems?TOTALSUMMARYHIGH CORTISOLLOW CORTISOLLOW PROGESTERONEEXCESS ESTROGENLOW ESTROGENEXCESS ANDROGENSLOW THYROIDSend Message
