ROYSTON CLINIC PRINTABLE FEMALE HORMONE CHECKLIST

These are symptoms associated with changes in natural hormones.  Score your symptoms 0 for no problem to 3 for severe problem. After completing a 4week, 12 weeks & 26 week program, re-evaluate your symptoms for comparison, to monitor improvements and allow fine tuning of treatment.

NAME:      

Symptom

0-3 score pre treatment

0-3 score @ 4 weeks

0-3 score @ 12 weeks

0-3 score @ 26 weeks

Symptom

0-3 score pre treatment

0-3 score @ 4 weeks

0-3 score @ 12 weeks

0-3 score @ 26 weeks

DATE:

 

 

 

 

DATE:

 

 

 

 

Forgetfulness

 

 

 

 

Decreased sexual desire

 

 

 

 

Headaches

 

 

 

 

Painful intercourse

 

 

 

 

Inability to concentrate

 

 

 

 

Difficult or loss of orgasm

 

 

 

 

Fuzzy thinking/Word searching

 

 

 

 

Loss of sexual fantasy

 

 

 

 

Emotional swings/Crying spells

 

 

 

 

Dry Vagina

 

 

 

 

Depression

 

 

 

 

Dry eyes

 

 

 

 

PMT

 

 

 

 

Hot flushes/ night sweats

 

 

 

 

Insomnia

 

 

 

 

Dry skin

 

 

 

 

Irritability

 

 

 

 

Skin crawling

 

 

 

 

Loss of interest in many things

 

 

 

 

Heart palpitations

 

 

 

 

Anxiety/Panic attacks

 

 

 

 

Breast swelling

 

 

 

 

Problems dealing with stress

 

 

 

 

Breast pain

 

 

 

 

Worry needlessly

 

 

 

 

Bloating

 

 

 

 

Backache

 

 

 

 

Fluid retention

 

 

 

 

Fatigue or Lethargy

 

 

 

 

Increased hip/thigh fat

 

 

 

 

Painful or aching joints

 

 

 

 

Weight gain

 

 

 

 

Burning with urination

 

 

 

 

Acne/pimples

 

 

 

 

Urine leaks with laughter/straining

 

 

 

 

 Nipple tenderness

 

 

 

 

Irritable bowel problems

 

 

 

 

Excess facial or body hair

 

 

 

 

 

 

 

 

 

Loss of hair from head