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Symptom Questionnaire

Completing the questionnaire below will provide you with an analysis of your symptoms. Our consultants will also review your results and we will contact you if we feel that you would benefit from a consultation.


Vasomotor (Adrenaline surges)
Hot flushes
Nil Mild Moderate Severe Cyclical
Night sweats
Nil Mild Moderate Severe Cyclical
Panic Attacks
Nil Mild Moderate Severe Cyclical
Palpitations
Nil Mild Moderate Severe Cyclical
Poor sleep / Sudden wakening
Nil Mild Moderate Severe Cyclical
Vivid dreams / Nightmares
Nil Mild Moderate Severe Cyclical
Mood / Concentration / Psychological
Tiredness
Nil Mild Moderate Severe Cyclical
Early morning / Mid-afternoon exhaustion
Nil Mild Moderate Severe Cyclical
Mood swings / Hypo and hyper active
Nil Mild Moderate Severe Cyclical
Aggressive / Short fuse
Nil Mild Moderate Severe Cyclical
Depressed / Low feeling
Nil Mild Moderate Severe Cyclical
Paranoid / Negative feelings
Nil Mild Moderate Severe Cyclical
Loss of confidence
Nil Mild Moderate Severe Cyclical
Reduced memory / Concentration / Attention deficit
Nil Mild Moderate Severe Cyclical
Disorientated / Out of body feeling
Nil Mild Moderate Severe Cyclical
Clumsy
Nil Mild Moderate Severe Cyclical
Insulin resistance / Glucose intolerance
Central abdominal weight gain
Nil Mild Moderate Severe Cyclical
Difficulty losing weight / Fluctuating weight
Nil Mild Moderate Severe Cyclical
Carbohydrate cravings / Unusual hunger
Nil Mild Moderate Severe Cyclical
Dizzy episodes
Nil Mild Moderate Severe Cyclical
Facial spots
Nil Mild Moderate Severe Cyclical
Increased facial hair
Nil Mild Moderate Severe Cyclical
Increased body hair
Nil Mild Moderate Severe Cyclical
Reduced scalp hair
Nil Mild Moderate Severe Cyclical
Bladder / Vaginal / Menstrual Symptoms
Urinary frequency
Nil Mild Moderate Severe Cyclical
Urinary urgency
Nil Mild Moderate Severe Cyclical
Getting up at night to pass urine
Nil Mild Moderate Severe Cyclical
Leaking on coughing / Straining
Nil Mild Moderate Severe Cyclical
Vaginal dryness / pain
Nil Mild Moderate Severe Cyclical
Lack of sexual interest / performance
Nil Mild Moderate Severe Cyclical
Vaginal discharge
Nil Mild Moderate Severe Cyclical
Change of menstrual cycle
Nil Mild Moderate Severe Cyclical
Bowel Related Symptoms
Early morning / constant nausea
Nil Mild Moderate Severe Cyclical
Bloating
Nil Mild Moderate Severe Cyclical
Abdominal pain
Nil Mild Moderate Severe Cyclical
Constipation / Irritable bowel
Nil Mild Moderate Severe Cyclical
Connective Tissue / Collagen Symptoms associated with hormone loss
Early morning / constant joint pains
Nil Mild Moderate Severe Cyclical
Dry, itchy eyes
Nil Mild Moderate Severe Cyclical
Blurred vision / Runny eyes
Nil Mild Moderate Severe Cyclical
Dry skin / Itchy skin / Brittle nails
Nil Mild Moderate Severe Cyclical
Dry ears / Itchy ears / Ringing ears
Nil Mild Moderate Severe Cyclical
Dry mouth / Mouth ulcers
Nil Mild Moderate Severe Cyclical
Thirsty, burning mouth, metallic taste
Nil Mild Moderate Severe Cyclical
Dry nose / Nose bleeds
Nil Mild Moderate Severe Cyclical
Increased skin irritation / eczema / rashes
Nil Mild Moderate Severe Cyclical
Vascular Symptoms (reduced blood flow due to arterial spasm)
Headaches
Nil Mild Moderate Severe Cyclical
Restless legs / Leg cramps
Nil Mild Moderate Severe Cyclical
Chest pain on exertion
Nil Mild Moderate Severe Cyclical
Cold hands and/or feet
Nil Mild Moderate Severe Cyclical
Poor healing / wound repair
Nil Mild Moderate Severe Cyclical
Vascular Symptoms (vein diseases - reduced strength of vein wall and muscle cramps)
Varicose veins - upper leg
Nil Mild Moderate Severe Cyclical
Varicose veins - lower leg
Nil Mild Moderate Severe Cyclical
Varicose veins - vulva
Nil Mild Moderate Severe Cyclical
Thread veins - legs
Nil Mild Moderate Severe Cyclical
Thread veins - trunk/facial
Nil Mild Moderate Severe Cyclical
Skin staining/discolouration
Nil Mild Moderate Severe Cyclical
Fluid retention
Nil Mild Moderate Severe Cyclical
Breast tenderness
Nil Mild Moderate Severe Cyclical
Crawling / itching skin
Nil Mild Moderate Severe Cyclical
Tingling fingers / toes
Nil Mild Moderate Severe Cyclical
Airways / Breathing
Snoring / Sleep Apnoea
Nil Mild Moderate Severe Cyclical
Shortness of breath
Nil Mild Moderate Severe Cyclical
Persistent Cough
Nil Mild Moderate Severe Cyclical
Additional Information

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