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Preliminary Hormonal Assessment

Preliminary Hormonal Assessment

Section 1: Menopause & PMS

Fully menopausal
In perimenopause
No, still having regular periods
Mood swings
Bloating
Acne
Hot flashes
Night sweats
Yes
No
Yes
Sometimes
No

Section 2: Skin & Hair Health

No
Occasionally
Frequently
Severe
No
Mild
Moderate
Severe
No
Mild
Moderate
Severe
No
Mild
Severe
Oily
Dry
Combination

Section 3: Gut Health

Yes
No
None
Mild
Moderate
Severe
Never noticed
Mild
Moderate
Severe
Fatigue
Gas
Bloating

Section 4: Medical History

PCOS
Thyroid
Yes
Sometimes
No
Yes
Sometimes
No
Yes
Don’t know
No
Yes
No
Yes
No

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