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Female Hormone Deficiency Questionnaire
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Fill out online or download & print to fill out offline.
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Female Hormone Deficiency Questionnaire
Name
First
Last
Email
Phone
Age
Weight
Height
Please answer each of the questions below by choosing 'Yes' or 'No'.
Do you have difficulty waking up in the mornings?
Yes
No
Do you always feel tired or exhausted?
Yes
No
Do you sleep poorly?
Yes
No
Are you frequently anxious, nervous or irritable?
Yes
No
Do you suffer from short- or long-term memory loss?
Yes
No
Do you have trouble concentrating?
Yes
No
Do you lack sexual desire?
Yes
No
Have you lost your attraction toward your partner?
Yes
No
Are you currently experiencing vaginal dryness?
Yes
No
Have you recently gained weight or do you have difficulty losing weight?
Yes
No
Do you carry your weight in your mid-section?
Yes
No
Have you lost muscle mass, tone and/or strength?
Yes
No
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