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Hormone Questionnaire

First Name*
Last Name*
Address*
City*
State*
Zip Code*
Age*  
Email*
Phone*
Hormones
Other Medications
Hysterectomy Yes No      Year 
Ovaries Removed   Yes No   
Please choose the number corresponding
to symptom intensity:
  0 = None  1 = Mild  2 = Moderate  3= Severe
1. Hot flushes, excessive sweating, and/or chilly sensations?
0   1  2  3
2. Sensations of numbness and/or tingling of arms, legs, or skin?
0  1  2  3
3. Restless, fragmented sleep; multiple awakenings?
0  1  2  3
4. Irritability, angry outbursts, feeling anxious or apprehensive?
0  1  2  3
5. Sad, depressed mood, unhappiness and/or being miserable without any obvious reason?
0  1  2  3
6. Sensations of dizziness, spinning and/or “swimming in the head”?
0  1  2  3
7. Feeling unusually fatigued, with a tiredness of mind and body associated with desire for rest; feeling a
lack of desire or motivation to make further efforts?
0  1  2  3
8. Pain or aches affecting joints or muscles?
0  1  2  3
9. Migraine, and/or tension headaches?
0  1  2  3
10.

Fluttering/pounding and/or rapid heartbeat in a sitting or resting position?
0  1  2  3
11. “Crawly skin” sensations, like ants or other insects creeping over the skin?
0  1  2  3
12. Diminished memory, concentration; feeling “foggy” brained?
0  1  2  3
  0 = Never 1 = Infrequently 2 = Sometimes
3 = Most of Time 4 = Always
13. Vaginal burning or itching?
0  1  2  3  4
14. Vaginal dryness, diminished lubrication during sexual arousal?
0  1  2  3  4
15. Painful urination or increased frequency of urination?
0  1  2  3  4
16. Leaking of urine during coughing, laughing, sneezing, or strenuous activity?
0  1  2  3  4
17. Leaking of urine during walking, running, climbing steps or light activity?
0  1  2  3  4
18. Leaking of urine, regardless of activity, even when in a lying position?
0  1  2  3  4

19.

 Increased urges to urinate, with difficulty holding back urination?
0  1  2  3  4
20. Sexual interest Normal Decreased
21. Intercourse in last two weeks? Yes No
22. Vulvar, vaginal or pelvic pain during intercourse?
Yes No
23. Reddish vaginal discharge after intercourse?
Yes No

24.

 Quality of orgasm Normal Decreased
25. Quality of lubrication Normal Decreased
 

 

 

Stacey M. Johnson, M.D.

Physicians' Medical Center of the Ozarks · 17 Medical Plaza · Mountain Home, AR 72653
Toll-Free 1-866-749-7633 · (870) 425-6212 · Fax (870) 424-3774 · www.physmedcenter.com

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09/25/2006 SJMD 301
Services About Physician's Medical Center Physicians and Staff Patient Care News and Events Resources Facility Patient Testimonials Patient Education View Videos Online Patient Education Contact Us Home Location / Maps Site Map View Videos Online MD Articles and Publications