Questions for Initial Consult
Name
Email
Ages of menarche
Age of menopause (if applicable)
Menses: length of cycle, days of flow, regularity, color / quality / quality of blood, PMS s/sx, LBP, spotting (mid-cycle before, or after period), breast tenderness, pain/cramping (where), stools with period, headaches, mood, digestion.
Ovulation: pain, breast tenderness, spotting (can she tell?)
QM dx: PCOS, PID, endometriosis, previous pregnancies/labor & delivery, duration of breast feeding (if at all), h/o anovulation, STIs, abnormal PAP smears (biopsy, colposcopy)- ask severity, duration and treatment
Family history (specifically frame relatives)
If on birth control - how long? Why did you start?
Pregnancy history (pregnancies and type of births, miscarriages, elective abortions, complications)
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
Painful periods
Short menstrual cycles (<21 days)
Bloating, fluid retention
Breast tenderness, cysts
Mood swings
Menstrual migraines
Uterine fibroids
Endometriosis
Varicose veins
Gallbladder problems
History of using estrogen-containing birth control or medication (in the last three months)
A pear-shaped body
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