Functional Medicine Health Assessment

Female-Hormone Balancing Questionnaire

Personal Information

FULL NAME *

TELEPHONE *

Email *

ADDRESS *

HOW DID YOU HEAR ABOUT US? *

DOB *

CURRENT AGE *

NATIONALITY *

WEIGHT/ HEIGHT/ BMI *

WHAT ARE YOUR MAIN CONCERNS? *

ARE YOU USING ANY HORMONE THERAPY? If none, please also state none *

Please select the right answer for you

Do you feel that your health has worsened over the past 2 years *

Have you ever lost or gained more than 10% of your body weight over the past 5 *

Do you have trouble going to sleep or staying asleep? *

Does pain in your joints or muscles limit your physical activity or mobility? *

Do you commonly feel fatigued for no apparent reason? *

Are you frequently depressed or anxious? *

Do you have memory issue? *

Is there consistent ringing in your ears? *

Do you feel that you are losing your strength? *

Do you any prescription medications: do you take more than two at a time? *

How about over-counter medications? Do you commonly take any of these: Anti- *

inflammatory, Antacids, Analgesics, Sleeping Remedies? *

Do you suffer from allergies? *

Do you occasionally have episodes of poor concentration or confusion? *

Do you commonly suffer from shortness of breath or feel wind up? *

ANY HISTORY IN THE PAST? Please say yes or no

Diabetes *

High Blood Pressure *

Heart Disease *

Autoimmune Disease. *

Skin Disease *

Allergies *

High Cholesterol *

Breathing Difficulty *

Clots in the blood/ deep vein thrombosis *

Cancer *

Breakfast/ Lunch/ Dinner *

HAVE YOU HAD ANY GYNAECOLOGICAL OR ANY OTHER SURGERIES IN THE PAST EG. HYSTERECTOMY (TOTAL OR SUBTOTAL) ETC.?

Please specify *

LIFESTYLE & EATING HABITS

BREAKFAST/ LUNCH/ DINNER. *

DO YOU DRINK ANY OTHER STIMULATES? *

DO YOU SMOKE? IF SO, HOW OFTEN, HOW MANY CIGARETTES OF GRAMS OF TOBACCO IF ROLLS *

DO YOU TAKE ANY SUBSTANCES (HARD DRUGS) OR STIMULANTS? *

HOW MUCH ALCOHOL INTAKE IN UNITS WEEKLY? *

SUPPLEMENTS INTAKE: WHAT KINDS, BRANDS *

MEDICATION INTAKE: WHICH ONE’S and HOW MUCH? *

SPORTS TYPES/ HOW OFTEN *

MEDITATION *

OTHER COMMENTS *

Please note that it is vital for us to receive your completed Menopause Symptom Questionnaire with any additional medical history information/ examination/ results you may wish to provide our medical team *

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Women's Hormone Health Event

Female-Hormone Balancing Questionnaire

Personal Information

Please select the right answer for you

ANY HISTORY IN THE PAST? Please say yes or no

HAVE YOU HAD ANY GYNAECOLOGICAL OR ANY OTHER SURGERIES IN THE PAST EG. HYSTERECTOMY (TOTAL OR SUBTOTAL) ETC.?

LIFESTYLE & EATING HABITS

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Female-Hormone Balancing Questionnaire

Personal Information

Please select the right answer for you

ANY HISTORY IN THE PAST? Please say yes or no

HAVE YOU HAD ANY GYNAECOLOGICAL OR ANY OTHER SURGERIES IN THE PAST EG. HYSTERECTOMY (TOTAL OR SUBTOTAL) ETC.?

LIFESTYLE & EATING HABITS

Locations

Therapy

About

Resources

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