Female Hormone Deficiency Questionnaire Fill out online or download & print to fill out offline. Download & Print Name First Last Number*AgeWeightHeightPlease answer each of the questions below by choosing 'yes' or 'no'.Do you have difficulty waking up in the mornings? Yes No Do you always feel tired or exhausted? Yes No Do you sleep poorly? Yes No Are you frequently anxious, nervous or irritable? Yes No Do you suffer from short- or long-term memory loss? Yes No Do you have trouble concentrating? Yes No Do you lack sexual desire? Yes No Have you lost your attraction toward your partner? Yes No Are you currently experiencing vaginal dryness? Yes No Have you recently gained weight or do you have difficulty losing weight? Yes No Do you carry your weight in your mid-section? Yes No Have you lost muscle mass, tone and/or strength? Yes No
