top of page

WOMEN'S HORMONE & VITALITY QUESTIONNAIRE

Awareness is the first step -- alignment is the path to transformation.​

​

This brief assessment explores how hormones, metabolism, sleep, stress and vitality may be shaping your well-being.

​

Once completed, you'll receive your results via email -- allowing you to review and reflect on your patterns at your own pace.

 

If you'd like help interpreting your insights or exploring next steps, you're welcome to request a complimentary 10-minute consultation anytime through the Resources page.

​

Your clarity begins here.

Results will be sent to Email

Instructions:

Choose the answer that best reflects how often you experience each symptom.

  • 0 = Never

  • 1 = Occasionally

  • 2 = Frequently

  • 3 = Almost always

ENERGY & METABOLISM

1. I feel fatigued even after a full night's sleep.

0=Never 1=Ocassionally 2=Frequently 3=Almost Always

2. My energy crashes in the afternoon.

0=Never 1=Ocassionally 2=Frequently 3=Almost Always

3. I have difficulty losing weight or maintaining weight.

0=Never 1=Ocassionally 2=Frequently 3=Almost Always

4. I crave sugar or carbs more often than usual.

0=Never 1=Ocassionally 2=Frequently 3=Almost Always

5. My metabolism feels "slower" than it used to.

0=Never 1=Ocassionally 2=Frequently 3=Almost Always

MOOD & MENTAL CLARITY

6. My mood fluctuates more than it used to.

0=Never 1=Ocassionally 2=Frequently 3=Almost Always

7. I feel irritable or emotionally sensitive.

0=Never 1=Ocassionally 2=Frequently 3=Almost Always

8. I have trouble concentrating or experience "brain fog."

0=Never 1=Ocassionally 2=Frequently 3=Almost Always

9. I feel anxious or overwhelmed more often than usual.

0=Never 1=Ocassionally 2=Frequently 3=Almost Always

10. I feel less resilient during stress.

0=Never 1=Ocassionally 2=Frequently 3=Almost Always

HORMONE CYCLES & PHYSICAL SYMPTOMS

11. My menstrual cycles are irregular or have changed recently
12. I experience hot flashes or night sweats.

0=Never 1=Ocassionally 2=Frequently 3=Almost Always

13. I have new or worsening PMS symptoms
14. My sleep quality is poor or interrupted.

0=Never 1=Ocassionally 2=Frequently 3=Almost Always

15. I notice changes in hair, skin, or nails (thinning, dryness, brittleness).

0=Never 1=Ocassionally 2=Frequently 3=Almost Always

LIBIDO & SEXUAL HEALTH

16. My libido is lower than it used to be.

0=Never 1=Ocassionally 2=Frequently 3=Almost Always

17. I experience discomfort during intimacy (dryness, pain, low arousal).

0=Never 1=Ocassionally 2=Frequently 3=Almost Always

18. I feel disconnected from my sense of sensuality or desire.

0=Never 1=Ocassionally 2=Frequently 3=Almost Always

19. I have difficulty reaching orgasm or feel less responsive than before.

0=Never 1=Ocassionally 2=Frequently 3=Almost Always

20. I avoid intimacy due to low energy or mood.

0=Never 1=Ocassionally 2=Frequently 3=Almost Always

METABOLIC & INFLAMMATION SIGNALS

21. I retain fluid more easily than before.

0=Never 1=Ocassionally 2=Frequently 3=Almost Always

22. I experience bloating or digestive irregularities.

0=Never 1=Ocassionally 2=Frequently 3=Almost Always

23. I gain weight around the belly more easily.
24. My blood sugar feels unstable (shakiness, dizziness, urgent hunger).

0=Never 1=Ocassionally 2=Frequently 3=Almost Always

25. I notice increased inflammation (joint pain, stiffness, puffiness).

0=Never 1=Ocassionally 2=Frequently 3=Almost Always

Consent and Acknowledgement

By submitting this form, I acknowledge that the information provided is truthful to the best of my knowledge. I understand that this questionnaire is for wellness and educational purposes only and does not establish a medical provider–patient relationship. I further understand that the results will be reviewed by Dr. Sandra McKenzie for the purpose of offering general wellness guidance or discussing next steps, and that any personalized recommendations will require a formal consultation.

This questionnaire is a screening tool, not a diagnosis.

Results help guide awareness and discussion.

Personalized recommendations require a clinical consultation.

bottom of page