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Women’s Hormone Deficiency Questionnaire
Allen Lawrence, M.D., Ph.D.
Advanced Wellness Medical Group
Phone: 310-879-9266 or 844-222-577
www.AdvancedWellnessMedical.com
Info@AdvancedWellnessMedical.com
Women’s Hormone Deficiency Questionnaire
If you have a deficiency of either Estrogen, Progesterone or Testosterone this can lead to a number of medical and health problems for you. Recognizing the symptoms associated with low female sex hormones listed below can help you. As you read the list below, ✓ the Yes box in front of those symptom which bother you. Next Rank each problem on a scale of 1-10 where 1 = ranks it as a minimal problem, and 10 = ranks it as a severe or significant problem. For Example: ✓Yes Night Sweats Rank 5 (out of 10)
| ✓ Yes |
Symptom | Rank |
✓ Yes |
Symptoms | Rank |
| Symptoms of Estrogen Deficiency | Progesterone Deficiency | ||||
| Hot Flashes and/or Warm Rushes | PMS | ||||
| Night Sweats | Fibroids (Benign Tumor in Womb) | ||||
| Hot and/or Cold Mood Swings | Endometriosis | ||||
| Mental Fogginess or Forgetfulness | Breast Tenderness & Pain | ||||
| Recurrent Headaches or Migraines | Breast Lumps and/or Breast Cysts | ||||
| Dry Vagina | |||||
| Dry Eyes and/or Dry Skin | |||||
| Loss of Personal Glow | Symptoms of Testosterone Deficiency | ||||
| Pain During Intercourse | Diminished Libido | ||||
| Insomnia, Sleep Disturbances | Loss of Sense of Security | ||||
| Racing Mind at Night | Diminished Energy and/or Weakness | ||||
| Frequent Fatigue and/or Low Stamina | Diminished Stamina | ||||
| Intestinal Bloating | Loss of Pubic Hair and/or Arm Pit Hair | ||||
| Diminished Sensuality and/or Sexuality | Loss of Muscle Mass, Flabbiness | ||||
| Loss of Interest in Sex, Low Libido | |||||
| Weight Gain, Thighs, Hips and/or Gluteus | |||||
Are You Estrogen, Progesterone or Testosterone Deficient? The Answer!
Women: If you have answered No to all of the questions above, then you are neither Estrogen, Progesterone or Testosterone Deficient.
Women: If you have answered Yes to more than 5 total questions or you rank greater than 5 on 3 or more questions, then you are either Estrogen, Progesterone or Testosterone Insufficient or Estrogen, Progesterone or Testosterone Deficient.
If you are Estrogen, Progesterone or Testosterone Insufficient or Estrogen, Progesterone or Testosterone Deficient you will likely benefit greatly from
Female – Bio-Identical Hormone Replacement Therapy (HRT).
I will be happy to talk with you and help you explore your options.
If you have questions or need help please call us at 310-879-9266 or 844-222-577 or send email to info@advancedwellnessmedical.com
