Female Hormone Deficiency Questionnaire

Name

First Last

Number*

Age

Weight

Height

Please answer each of the questions below by choosing 'yes' or 'no'.

Do you have difficulty waking up in the mornings?

Do you always feel tired or exhausted?

Do you sleep poorly?

Are you frequently anxious, nervous or irritable?

Do you suffer from short- or long-term memory loss?

Do you have trouble concentrating?

Do you lack sexual desire?

Have you lost your attraction toward your partner?

Are you currently experiencing vaginal dryness?

Have you recently gained weight or do you have difficulty losing weight?

Do you carry your weight in your mid-section?

Have you lost muscle mass, tone and/or strength?