Hormonally Balanced
Root Cause Assessment Questionnaire



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To what extent do you suffer from excessively dry skin or hair?






Is your skin becoming thin?






To what extent do you suffer from dry eyes?






To what extent do you suffer from feeling cold or a low body temperature?






To what extent do you suffer from unexplained hoarseness?






To what extent do you suffer from recent frequent, intense headaches?






To what extent do you suffer from abdominal fluid retention?






To what extent do you suffer from urinary incontinence?






To what extent do you suffer from painful intercourse?






To what extent do you experience a lack of interest in sex?






To what extent have you felt a decrease in your level of sexual sensation?






To what extent do you suffer from cold extremities?






To what extent do you suffer from fluid retention (edema)?






To what extent do you suffer from a decrease in your physical stamina?






To what extent do you suffer from chronic fatigue?






To what extent do you suffer from difficulty with memory or recall?






To what extent do you suffer from night sweats?






To what extent do you suffer from anxiety?






To what extent do you suffer from lack of interest in life (apathy)?






To what extent do you suffer from difficulty with concentration and focus?






To what extent do you suffer from a depresssed mood?






To what extent do you suffer from emotional irritability?






To what extent do you suffer from mood swings?






To what extent do you suffer from difficulty staying asleep?






To what extent do you suffer from unexplained weight gain or difficulty controlling your weight?






To what extent do you struggle with hair loss or hair thinning?






To what extent do you suffer from breast tenderness?






To what extent do you suffer from hot flashes?






To what extent do you suffer from vaginal dryness?






To what extent do you struggle with muscle pain or chronic pain?






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