Hormones Evaluation Quiz

Answer a few questions about your energy, sleep, mood, weight, libido, menstrual health, and overall well-being. Your responses can help guide whether a complimentary consultation or further hormone evaluation may be appropriate.

Divine Health Assessment - Combined

First Name

Last Name

Gender / Assessment Type

Phone

Symptoms

Please mark the appropriate box for each symptom you may be experiencing.

Physical Exhaustion (fatigue, lack of energy, stamina or motivation)

Decline in drive or interest (loss of “zest for life,” feeling down or sad)

Difficulties with memory (concentration, finding the right word, or retaining information)

Irritability (mood swings, feeling aggressive, angers easily)

Feeling cold all the time, having cold hands or feet

Weight (difficulty losing weight despite diet/exercise)

Sexual Problems (change in desire, activity, orgasm and/or satisfaction)

Hot Flashes (burst that starts in chest and lasts for short duration)

Anxiety (feeling overwhelmed, feeling panicky, or feeling nervous)

Vaginal dryness or difficulty with sexual intercourse

Sweating (night sweats or increased episodes of sweating)

Sleep Problems (difficulty falling asleep or sleeping through the night)

Joint and muscular symptoms (joint pain, muscle weakness, poor recovery after exercise)

Bladder problems (difficulty in urinating, increased need to urinate, incontinence)

Hair loss, thinning or change in texture of hair

Headaches or migraines (increase in frequency or intensity)