Hormone & Weight Loss Questionnaire

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Physical Exhaustion (fatigue, lack of energy, stamina or motivation)

Sleep Problems (difficulty falling asleep or sleeping through the night)

Irritability (mood swings, feeling aggressive, angers easily)

Anxiety (feeling overwhelmed, feeling panicky, or feeling nervous)

Decline in drive or interest (loss of "zest for life," feeling down or sad)

Joint and muscular symptoms (joint pain, muscle weakness, poor recovery after exercise)

Difficulties with memory (concentration, finding the right word, or retaining information)

Sexual Problems (change in desire, activity, orgasm and/or satisfaction)

Hair loss, thinning or change in texture of hair

Sweating (night sweats or increased episodes of sweating)

Feeling cold all of the time, having cold hands or feet

Headaches or migraines (increase in frequency or intensity)

Weight (difficulty losing weight despite diet/exercise)

Bladder problems (difficulty in urinating, increased need to urinate, incontinence)

Other symptoms or unique health circumstances to take into consideration:

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