Women's Health + Hormone Questionnaire

At the Metabolic Makeover Academy we strive to achieve OPTIMAL health through proper nutrition, training, habits, and functional testing (when needed). Not another diet, but a lifestyle. Not JUST for weight loss, but for the highest level of well-being.

As a team of functional nutritionists, we understand the power that your hormones have over every aspect of your life and yet receiving help can often feel impossible. We strive to change that narrative!

Please take a minute to complete this hormone health assessment meant not to diagnose you of anything, but rather to uncover the symptoms that may be hinting to a hormonal imbalance.

*Note: This is not medical advice. Source-"Beyond the Pill". ONLY available to those who reside in the U.S. and are over the age of 21*

First Name *

Last Name *

Email *

Date of birth *

Are you currently taking hormonal birth control? *

Are you currently in menopause? *

Do you get a regular menstrual cycle? *

Please list any relevant health history or diagnosis (i.e. hysterectomy, post-partum, PCOS, Endometriosis, autoimmune condition): *

Category A: Please select each statement you feel you identify with: *

I sometimes experience bloating or puffiness.

I often feel irritable or experience mood swings.

I experience heavy, painful periods.

I have gained weight or have difficulty losing weight, especially around my hips, butt, and thighs.

I have been told by my doctor that I have fibroids.

I sometimes cry over “nothing”.

I often get migraines or other headaches.

I sometimes experience brain fog.

None of the above.

Your diet has one of the largest influences on your hormone health. In a short overview, what does your diet consist of? *

Equally as impactful is your exercise regiment. In a brief overview, what does your weekly activity consist of? *

How would you rate your stress levels? *

Low

Moderate

High

Extreme

Is there anything else you would like us to know?

Thank you for taking the time to complete this assessment. You will now be redirected to our calendar to book your complimentary 15-minute feedback call with Audrey or Mason to review your results!