Complete the questionnaire below to help find out whether your current symptoms may be due to your hormones.

Developed by our experts, this questionnaire is often used by doctors as part of their assessment of a woman's symptoms and to monitor the results of treatment.

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* 1. Full Name

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* 2. Contact Number

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* 3. Email Address

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* 4. Vasomotor (Adrenaline Surges)

  Nil Mild Moderate Severe Cyclical
Hot Flushes
Night Sweats
Panic Attacks
Palpitations
Poor Sleep/sudden waking
Vivid dreams/nightmares

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* 5. Mood/Concentration/Psychological

  Nil Mild Moderate Severe Cyclical
Tiredness
Early morning/mid-afternoon exhaustion
Mood wings/Hypo and hyper active
Aggressive/short fuse
Depressed/low feeling
Paranoid/negative feelings
Loss of confidence
Reduced memory/concentration/attention deficit
Disorientated/out of body feeling
Clumsy

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* 6. Insulin resistance/glucose intolerance

  Nil Mild Moderate Severe Cyclical
Central abdominal weight gain
Difficulty losing weight/fluctuating weight
Carbohydrate cravings/unusual hunger
Dizzy episodes
Facial Spots
Increased facial/body hair
Reduced scalp hair

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* 7. Bladder/Vaginal/Menstrual Symptoms

  Nil Mild Moderate Severe Cyclical
Urinary frequency
Urinary urgency
Getting up at night to pass urine
Leaking on coughing/straining
Vaginal dryness/pain
Lack of sexual interest/performance
Vaginal discharge
Change of menstrual cycle

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* 8. Bowel related Symptoms

  Nil Mild Severe Cyclical
Early morning/constant nausea
Bloating
Abdominal pain
Constipation/irritable bowl
Thank you for completing your questionnaire. A specialist member of the team will be in touch with you shortly.

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