Kim Conway - Integrative Wellness Consultant
Hormone Symptom Checklist
All of your information will remain confidential.
Please check all that apply to you:
Abnormal pap smears (one or more?)
Bloating and/or fluid retention (perhaps you gain before your period?)
Bone loss, such as osteopenia and/or osteoporosis
Brain fog, or difficulty concentrating, or feel slow, a bit apathetic
Cold hands and feet - wear socks to bed
Constipation- poop less than once per day, without caffeine to trigger
Cyclical headaches (particularly menstrual or hormonal migraines)
Droopy boobs, or breasts lessening in volume?
Fatigue, sleepy, joint aches and pains
Feel weak, and it limits your ability to exercise
Hair loss or dry, straw-like hair?
Have a tendency toward anemia
Low blood pressure / dizziness standing up from lying down or seated
Headaches or accelerated aging, such as wrinkles before your time
Heavy or painful menstruation or endometriosis or miscarriage
High blood pressure
Increased belly fat, which some call a “muffin top”
Infertility or subfertility (you’ve been trying to conceive for 6 months +)
Low stress resilience, and/or feel overwhelmed most of the time
Memory lapses or feeling distracted, especially under duress
Muscle or joint pain
Painful or tender breasts, especially 7 - 10 days prior to your period
PMS (Premenstrual Syndrome)
Poor memory or drawing a blank mid-sentence
Shakiness between meals, or irritability, also known as hypoglycemia
Sleep problems, difficulty winding down, disrupted sleep 1-4 a.m.
Trouble losing weight - your metabolism feels slower than everyone's
Vaginal dryness, irritation, or loss of feeling
Cysts - ovarian, breast, or endometrial cysts (polyps)
A red flush on your face (or a diagnosis of rosacea)
Heavy bleeding or postmenopausal bleeding or fibroids
Hot flashes, night sweats, or power surges
Weepiness, or mini-breakdowns/anxiety
Gall bladder problems or removal
Excess hair on your face, chest, or arms
Thinning head hair
Discoloration of your armpits (darker & thicker than your normal skin)
Skin tags, especially on your neck and upper torso
Unstable blood sugar, hyperglycemia or hypoglycemia
Menstrual cycles occurring more than every 35 days or infertility
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