Hormone Balance Questionnaire
Most women are surprised to learn that the symptoms they've been struggling with for months or years are really potentially signs of an underlying hormonal imbalance. It is time to stop suffering! There are numerous ways to treat and manage hormones. The following questions are designed to assess your own hormonal health, and to help you on your journey towards personal wellness. 100 years ago the average life expectancy of women was 50 years old which corresponds to the average time of menopause. Today, our life expectancy is well into the 80s and 90s affording us a long life, but possibly a life less vibrant. Many women today live with symptoms of hormonal imbalances because they may not know there are options out there to manage your hormones and get your life back. Please take the assessment below to determine your current hormonal situation. Tell us about how you are feeling over the last 3-6 months.
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1. Often
2. Intermittent
3. Seldom to never

2. I have gained weight over the last year especially around the mid-section.

1. Yes
2. No

3. I experience irregular periods or intermittent periods.

1. Yes
2. No

4. I do not feel refreshed when I wake up.

1. Often
2. Intermittent
3. Seldom to never

5. My sex drive is not what it used to be.

1. Severe
2. Moderate
3. Mild
4. Not a problem

6. I struggle with sadness and depression.

1. Severe
2. Moderate
3. Mild
4. Not a problem

7. I feel especially fatigued in the afternoon.

1. Often
2. Intermittent
3. Seldom to never

8. I feel frazzled or overwhelmed.

1. Often
2. Intermittent
3. Never

1. Severe
2. Moderate
3. Mild
4. Not a problem

1. Severe
2. Moderate
3. Mild
4. Not a problem

1. Severe
2. Moderate
3. Mild
4. Not a problem

1. Severe
2. Moderate
3. Mild
4. Not a problem

1. Often
2. Intermittent
3. Seldom to never

1. Often
2. Intermittent
3. Seldom to never

15. I have experienced a major life event or trauma in the last 3 years.

1. Yes
2. No

1. Yes
2. No

1. Yes
2. No

1. Yes
2. No

1. Often
2. Intermittent
3. Seldom to never

1. 3 - 4 or more times a week
2. 2 or less times a week
3. Sporadic exercise

1. Yes
2. No