Hormone Symptom Questionaire – Autonomic Coaching

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Hormone Symptom Questionnaire

Name

Name

First

First

Last

Last

Gender

Male

Female

Email

Phone

Date

Difficulty Concentrating *

0

1

2

3

Difficulty Concentrating *

Increased Forgetfulness *

0

1

2

3

Increased Forgetfulness *

Foggy Thinking *

0

1

2

3

Tearful *

0

1

2

3

Depressed *

0

1

2

3

Mood Swings *

0

1

2

3

Fluid Retention / Bloating *

0

1

2

3

Stress *

0

1

2

3

Anxious *

0

1

2

3

Irritable *

0

1

2

3

Nervous *

0

1

2

3

Decreased Mental Sharpness *

0

1

2

3

Morning Fatigue *

0

1

2

3

Afternoon Fatigue *

0

1

2

3

Evening Fatigue *

0

1

2

3

Excessive Worry *

0

1

2

3

Difficulty Falling Asleep *

0

1

2

3

Difficulty Staying Asleep *

0

1

2

3

Decreased Stamina *

0

1

2

3

Diminished Motivation *

0

1

2

3

Fibromyalgia *

0

1

2

3

Ringing in Ears *

0

1

2

3

Allergies *

0

1

2

3

Headaches/Migraines *

0

1

2

3

Dizzy Spells *

0

1

2

3

Sugar Cravings *

0

1

2

3

Addictive Behavior *

0

1

2

3

Poor Impulse Control *

0

1

2

3

Obsessive Behaviors (OCD) *

0

1

2

3

Craving Food, Alcohol, *

0

1

2

3

Tobacco or Other *

0

1

2

3

Constipation *

0

1

2

3

Goiter *

0

1

2

3

Cold Body Temperature *

0

1

2

3

Hoarseness *

0

1

2

3

Hair Dry or Brittle *

0

1

2

3

Nails Breaking or Brittle *

0

1

2

3

Slow Pulse Rate *

0

1

2

3

Rapid Heartbeat *

0

1

2

3

Heart Fluttering/Palpitations *

0

1

2

3

Incontinence *

0

1

2

3

Hot Flashes *

0

1

2

3

Night Sweats *

0

1

2

3

Infertility Concerns *

0

1

2

3

Acne *

0

1

2

3

Scalp Hair Loss *

0

1

2

3

Weight Gain-Hips *

0

1

2

3

Weight Gain-Waist *

0

1

2

3

High Cholesterol *

0

1

2

3

Elevated Triglycerides *

0

1

2

3

Decreased Libido *

0

1

2

3

Decreased Muscle Mass *

0

1

2

3

Decreased Flexibility *

0

1

2

3

Burned Out Feeling *

0

1

2

3

Sore Muscles *

0

1

2

3

Increased Joint Pain *

0

1

2

3

Neck or Back Pain *

0

1

2

3

Bone Loss *

0

1

2

3

Thinning Skin *

0

1

2

3

Rapid Aging *

0

1

2

3

Aches and Pains *

0

1

2

3

IBS *

0

1

2

3

Height (inches)

Weight (lbs)

Women Only

Vaginal Dryness

0

1

2

3

Irregular Periods

0

1

2

3

Uterine Fibroids

0

1

2

3

Tender Breasts

0

1

2

3

Fibrocystic Breasts

0

1

2

3

Increased Facial / Body Hair *

0

1

2

3

Last Menses

Men Only

Decreased Urine Flow

0

1

2

3

Increased Urinary Urge

0

1

2

3

Prostate Problems

0

1

2

3

Decreased Erections

0

1

2

3

If you are human, leave this field blank.

About Us:

Questions:

info@autonomiccoaching.com

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