Female Hormone Symptom Tracker Questionnaire

Last Name

First Name

Instructions:
Please rate how often you have experienced the following symptoms in the past 2 weeks using the scale below:

0 – Never

1 – Occasionally (once or twice)
2 – Often (3–5 times)
3 – Frequently (more than 5 times or daily)

Estrogen Imbalance (High or Low)

Irregular periods
Heavy or light periods
Breast tenderness or swelling
Bloating
Mood swings / irritability
Hot flashes / night sweats
Headaches (cyclical)
Vaginal dryness
Low libido
Fatigue

0 – Never

1 – Occasionally (once or twice)
2 – Often (3–5 times)
3 – Frequently (more than 5 times or daily)

Progesterone Deficiency

Anxiety or restlessness
Insomnia or trouble staying asleep
PMS symptoms worsening before periods
Short menstrual cycles (<25 days)
Spotting before period
Low mood or depression (especially premenstrual)
Fluid retention

0 – Never

1 – Occasionally (once or twice)
2 – Often (3–5 times)
3 – Frequently (more than 5 times or daily)

Testosterone Imbalance (High or Low)

Low libido 1
Decreased muscle tone / strength
Fatigue or lack of motivation
Thinning hair or hair loss (scalp)
Acne (jawline/chin area)
Facial/body hair growth (hirsutism)

0 – Never

1 – Occasionally (once or twice)
2 – Often (3–5 times)
3 – Frequently (more than 5 times or daily)

Cortisol / Stress Hormone Imbalance

Trouble falling asleep or waking too early
Feeling “tired but wired”
Cravings for sugar or salt
Feeling overwhelmed easily
Midsection weight gain
Brain fog or memory issues
Energy crash mid-afternoon

0 – Never

1 – Occasionally (once or twice)
2 – Often (3–5 times)
3 – Frequently (more than 5 times or daily)

Thyroid Dysfunction (Hypo/Hyper)

Cold hands and feet
Constipation
Hair thinning or hair loss
Unexplained weight changes
Puffy face or eyes
Depression or sluggishness
Rapid heartbeat or palpitations
Anxiety or nervous energy

Additional Notes or Symptoms to Report:

Date of Completion *