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    Your Hormone Blueprint Questionnaire

    Uploaded by

    Andreea Ciaus
    This document contains an 8-pattern hormone blueprint questionnaire to help users identify potential hormone imbalances. It lists common symptoms for patterns of high or low estrogen, progesterone, testosterone, cortisol, thyroid hormone, and insulin/insulin resistance. Scoring higher than 4 points in a pattern suggests an imbalance, and over 8 points suggests a more significant imbalance. The goal is to address any imbalances through the hormone intelligence plan.

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    Your Hormone Blueprint Questionnaire

    Uploaded by

    Andreea Ciaus
    217 views4 pages
    This document contains an 8-pattern hormone blueprint questionnaire to help users identify potential hormone imbalances. It lists common symptoms for patterns of high or low estrogen, progesterone, testosterone, cortisol, thyroid hormone, and insulin/insulin resistance. Scoring higher than 4 points in a pattern suggests an imbalance, and over 8 points suggests a more significant imbalance. The goal is to address any imbalances through the hormone intelligence plan.

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    This document contains an 8-pattern hormone blueprint questionnaire to help users identify potential hormone imbalances. It lists common symptoms for patterns of high or low estrogen, progesterone, testosterone, cortisol, thyroid hormone, and insulin/insulin resistance. Scoring higher than 4 points in a pattern suggests an imbalance, and over 8 points suggests a more significant imbalance. The goal is to address any imbalances through the hormone intelligence plan.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    217 views4 pages

    Your Hormone Blueprint Questionnaire

    Uploaded by

    Andreea Ciaus
    This document contains an 8-pattern hormone blueprint questionnaire to help users identify potential hormone imbalances. It lists common symptoms for patterns of high or low estrogen, progesterone, testosterone, cortisol, thyroid hormone, and insulin/insulin resistance. Scoring higher than 4 points in a pattern suggests an imbalance, and over 8 points suggests a more significant imbalance. The goal is to address any imbalances through the hormone intelligence plan.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    HORMONE INTELLIGENCE

    HORMONE BLUEPRINT QUESTIONNAIRE

    Use this self-assessment to help you connect the dots and to track improvement as you go through the
    plan and beyond. Scoring >4 points in any of the 8 patterns suggests that you have some measure of
    the associated imbalance. Scoring >8 points in any section suggests a more significant imbalance. It’s
    common—in fact likely—to have more than one imbalance. The Hormone Intelligence Plan is all about
    addressing these symptoms and imbalances!

    Check all boxes that relate to you in each section.

    Pattern 1: High Estrogen

    Heavy periods
    Endometriosis
    Painful periods
    Varicose veins
    Short menstrual cycles (<21 days)
    Gallbladder problems
    Bloating, fluid retention
    History of using estrogen-containing
    Breast tenderness, cysts
    birth control or medication (in the
    Mood swings
    last three months)
    Menstrual migraines
    A pear-shaped body
    Uterine fibroids
    YOUR SCORE____________

    Pattern 2: Low Estrogen

    Irregular or absent periods


    Brain fog, memory problems, poor focus
    Trouble falling asleep, waking in the
    Long menstrual cycles or scant periods
    middle of the night
    Migraines
    Anxiety, depression
    Joint aches or pains
    Hot flashes, night sweats
    Loss of bone density (osteopenia,
    Vaginal dryness
    osteoporosis, loss of height)
    Urinary frequency or frequent UTIs
    Autoimmune disease
    Low libido
    YOUR SCORE____________
    Weight gain

    www.avivaromm.com ©Aviva Romm MD 2021


    Pattern 3: Low Progesterone

    Irregular menstrual cycles


    Spotting in the second half of your cycle
    Heavy periods
    Low or no signs of ovulation
    Insomnia, sleep problems
    Low basal body temp in the luteal phase
    Headaches or migraines
    Fertility problems
    Anxiety, depression
    Low libido
    PMS
    Breast tenderness, fibrocystic breasts
    Short luteal phase (ovulation to
    Fibroids
    menstruation less than 12 days)
    Gallbladder problems
    Recurrent miscarriage
    Endometriosis
    Symptoms of excess estrogen (see book)
    YOUR SCORE____________

    Pattern 4: High Testosterone

    Irregular periods
    Acne
    Skipped periods
    Weight gain
    Fertility challenges
    Aggression, irritability
    Hair in unwanted places
    Polycystic ovary syndrome (PCOS)
    Hair loss (head)
    High LDL cholesterol
    YOUR SCORE____________

    Pattern 5: Low Testosterone

    Fatigue, sluggishness
    Low sex drive
    Low motivation
    Decreased sexual satisfaction,
    Depression
    difficulty achieving orgasm
    Muscle weakness or loss of muscle
    Weight gain
    Hair loss
    Irregular menstrual cycles
    Sleep disturbances
    YOUR SCORE____________

    www.avivaromm.com ©Aviva Romm MD 2021


    Pattern 6: High Cortisol

    Chronic stress, overwhelm Low (or no) sex drive


    Low motivation or drive Overweight, especially around my
    Often feeling burnout middle (“muffin top”)
    Trouble falling asleep, feeling “tired and wired” Blue or even depressed
    Tired during the day, hit a slump around 3–4 p.m. Increased skin wrinkling for your age
    Waking up tired even after a good Reduced memory or focus
    night’s sleep Irregular menstrual cycles
    Insomnia, trouble falling asleep or Miserable menopausal symptoms
    staying asleep Trouble getting pregnant, history of
    Needing coffee to start the day, or a miscarriage
    cup in the afternoon PCOS
    Craving sweets, chocolate, or salty foods High cholesterol
    Bloating, puffiness, or fluid retention Bone loss (osteopenia or osteoporosis)
    Mood swings, PMS, irritability, Autoimmune disease
    weepiness, mini breakdowns, or anxiety Frequent colds or illnesses
    YOUR SCORE____________

    Pattern 7: Low Thyroid Hormone

    Sluggishness, fatigue, zero energy


    Brittle or coarse hair or nails
    Weight gain without changing eating or
    Hair loss, hair thinning
    exercise habits
    High cholesterol
    Trouble losing weight, despite dieting
    Puffiness around eyes, face gets puffy
    and exercise
    Loss or thinning of outer third of
    My memory and concentration aren’t
    eyebrows
    what they were
    PMS, heavy periods, or skipped periods
    Low mood, depression, anxiety
    Trouble getting pregnant, history of
    Sluggish bowels, constipation
    miscarriage
    Feeling cold all the time, have to wear a
    History of postpartum depression or
    sweater even if nobody else is, low body
    trouble producing breast milk
    temperature
    YOUR SCORE____________
    Dry, itchy, or rough skin

    www.avivaromm.com ©Aviva Romm MD 2021


    Pattern 8: High Insulin / Insulin Resistance

    High blood sugar Frequent thirst, frequent urination


    Metabolic syndrome, insulin resistance, or Waist circumference >30 inches
    diabetes High blood pressure (>130/80)
    Shakiness or agitation between meals History of gestational diabetes or had a
    Skin tags baby who weighed more than 9 pounds
    Brown, velvety skin discoloration in my PCOS
    armpits, groin, or neck Hair in unwanted places
    Tired a lot Hair thinning or loss
    Overweight, with weight especially Acne, especially cystic acne
    around my waist and belly YOUR SCORE____________

    www.avivaromm.com ©Aviva Romm MD 2021

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