Menopause Symptom Questionnaire

ANY HISTORY IN THE PAST? Please say yes or no

Past Diabetes *

Past High Blood Pressure *

Past Heart Disease *

Past Autoimmune Disease *

Past Skin Disease *

Past Allergies *

Past High Cholesterol *

Past Breathing Difficulty *

Past Cancer *

Past Clots in the blood/ deep vein thrombosis *

Please state a relative and age of relative if the *

DO YOU SUFFER FROM THE FOLLOWING? If yes, please specify *

Tiredness

Bloating *

Suffer Irritability *

Breast Tenderness *

Suffer Headaches *

Depression *

Aching joints *

Hot flushes/ Night sweats *

Dry skin *

Weight-gain/ Weight-loss *

Cold feet & hands *

Brain fog *

Poor memory *

Constant forgetfulness *

Urinary needs/ incontinence *

Mood swings *

Stress *

Any other bodily change/s *

Please specify *

LIFESTYLE & EATING HABITS

Breakfast/ Lunch/ Dinner *

Are you vegetarian/ vegan? *

How much water do you drink *

Do you drink any other stimulates *

Do you smoke *

Sleeping habits *

Any hard drug *

How much alcohol intake *

Supplements intake what kinds, brands *

Sports types/ how often *

MEDITATION/ BREATHWORK *

Other Comments

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Hormone Balancing Questionnaire - Part 2

ANY HISTORY IN THE PAST? Please say yes or no

DO YOU SUFFER FROM THE FOLLOWING? If yes, please specify *

LIFESTYLE & EATING HABITS

Lifestyle & Eating Habits

Locations

Therapy

About

Resources

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Hormone Balancing Questionnaire - Part 2

ANY HISTORY IN THE PAST? Please say yes or no

DO YOU SUFFER FROM THE FOLLOWING? If yes, please specify *

LIFESTYLE & EATING HABITS

Lifestyle & Eating Habits

Locations

Therapy

About

Resources

Discovery call

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