My Doctor Never Asked - Hormonal Balance

Find Out if You Have HES

Fill out this questionaire and see your total score.

Score

1. Personal Information

Name

Age Height Weight Pounds overweight

Total Years of Education

2. Menstrual Status (check all that apply)

still have periods
irregular periods
severe menstrual carmps
large clots in menstrual flow
long periods (7+ days)
heavy periods (pad/tampon lasts 2 hrs. or less)
one ovary removed
both ovaries removed
uterus removed
postmenopausal, no periods since

3a. Hormonal Status (for women BEFORE menopause)

take no hormones
birth control pills (estrogen/progesterone)
mini pills (progesterone only)
depo provera shot
birth control patch
Name of hormone prescription

3b. Hormonal Status (for women DURING / AFTER menopause)

take no hormones
soy estrogen replacement
progesterone cream replacement
oral estrogen replacement
oral estrogen & oral progesterone replacement
patch estrogen replacement
patch estrogen & oral progesterone replacement
patch estrogen & patch progesterone replacement
Name of hormone prescription

4. Gyn History (check all that apply)

last PAP/pelvic exam done by Gynecologist/Obstetrician
last PAP/ pelvic exam done by Family Practice MD/Internal Med
last PAP/ pelvic exam less than 6 months ago
last PAP/ pelvic exam less than 1 year ago
last PAP/ pelvic exam less than 2 years ago
last PAP/ pelvic exam more than 2 years ago
never had PAP/ pelvic exam

breast cysts/lumps
abnormal PAPS/cervical dysplasia/genital herpes
uterine fibroids
ovarian cysts
miscarriage
breast cancer
cervical cancer
uterine cancer
ovarian cancer

5. Which of the following have you had in the past year? (check all that apply)

tension headaches
migraine headaches
acne
breast tenderness
abdominal bloating
constipation (2 days or more w/o BM)
food cravings/increased appetite
weight gain (more than 5 lbs)
fatigue/sleeping a lot
depression/feeling unmotivated
anxiety/worried a lot
sever mood swings/panic attacks
poor concentration/feeling spacey and forgetful
low sex drive/poor vaginal lubrication

Were you ever told you had a hormone imbalance or PMS? No Yes

If yes, when?
Diagnosis?
Treatment?
How did the treatment work?

I would like treatment for the symptoms in section 5.

Marguerite Vardman APRN ANP Body, Mind, & Spirit Healthcare P O Box 302 Lincolnton, GA 30817-0302
The advice offered on this website is not intended to be a substitute for the advice and counsel of your personal physician. Please consult your physician before starting this treatment program. Also, you may encourage your physician to read the book and/or contact the author for further information on the diagnosis and treatment of Hyperestrogen Syndrome.

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