FIND OUT HOW WELL YOUR HORMONES ARE FUNCTIONING BY ANSWERING A FEW SIMPLE QUESTIONS
(and we’ll share a few tips on how to take steps to help balance them!)
WHY DO YOU NEED A HORMONE HEALTH ASSESSMENT?
YOU'RE STRUGGLING WITH STUBBORN WEIGHT, LOW ENERGY, OR HORMONAL SYMPTOMS THAT WON'T GO AWAY.
YOU WANT TO IMPROVE YOUR FERTILITY.
YOU WANT TO FIX YOUR HORMONES AND METABOLISM WITHOUT EXTREME DIETING OR BURNOUT.
YOU WANT TO FIX YOUR CYCLE.
YOU WANT TO GET OUT OF SURVIVAL MODE AND STOP FEELING DRAINED ALL THE TIME.
YOU WANT TO FIX YOUR HORMONES NATURALLY INSTEAD OF RELYING ON BAND-AID SOLUTIONS.
First, lets get your name!
2 of 20
Do you have any medical conditions you wish to disclose? (I.E. diabetes, hypothyroid, high cholesterol, etc) *
3 of 20
Are you...
Pre-Menopausal
Peri-menopausal
Post-menopause
5 of 20
How many calories on average are you eating per day?(if not tracking, provide a rough estimate) *
6 of 20
How would you rate your daily energy levels? *
7 of 20
How would you rate your daily stress levels? *
8 of 20
How active are you? *
Sedentary
Moderately Active
Active
Highly Active
9 of 20
This assessment is not about coaching but are you interested in hearing more about 1 on 1 coaching? *
10 of 20
A. Select which symptoms apply to you.
Choose as many as you like
I'm irritable or experience mood swings
I have bloating or puffiness
I have heavy and painful periods
I've gained weight or have difficulty losing weight
I have fibroids
I have emotional outbursts over nothing
I get migraines or other headaches
I have brain fog
I have gallbladder problems or it has been removed
N/A
11 of 20
B. Select which symptoms apply to you.
Choose as many as you like
I'm emotionally fragile and/ or I feel nostalgia about the past, I have difficulty with memory
My periods are fewer than 3 days
I struggle with depression, anxiety, or lethargy
I have night sweats and/or hot flashes
I've had trouble with recurring bladder infections
I sometimes have problems with urinary leakage
I have difficulty sleeping and wake at night
My breasts are smaller and beginning to droop
I have achy joints or am prone to joint injuries
N/A
12 of 20
B. Select which symptoms apply to you.
Choose as many as you like
My sun-damaged skin is more noticable
I am noticing more fine lines and wrinkles
I have dry or thinning skin
I use NSAIDS like ibuprofen or naproxen regularly
I have no interest in sex
I have vaginal dryness or pain with intercourse
N/A
13 of 20
C. Select which symptoms apply to you
I experience PMS seven to ten days before my period
I get headaches or migraines around my period
I feel anxious often
I have painful, heavy, or difficult periods
My breasts are painful or swollen before my period
I feel agitated, irritable, or weepy before my period
I have had a miscarriage in the first trimester
I experience restless legs, especially at night
I have had difficulty getting pregnant (after trying for six or more months)
N/A
14 of 20
D. Select which symptoms apply to you
I have abnormal hair growth on my face, chest, and/or abdomen
I have acne
I have oily skin and/or hair
I have areas of darker skin (eg: armpits)
I have noticed thinning hair on my head
I have skin tags
I struggle with depression and/or anxiety
I have PCOS
I have had difficulty getting pregnant (after trying for six or more months).
N/A
15 of 20
E. Select which symptoms apply to you
I have a low libidio or diminished sex drive
I struggle with depression, have mood swings, or cry easily
I have no motivation
I am tired or fatigued throughout the day or have been diagnosed with chronic fatigue syndrome
I am unable to gain muscle, and I'm losing muscle mass
I have a decrease in bone density or have been diagnosed with osteopenia or osteoporosis
I have urinary incontinence
I have difficulty or am unable to orgasm
I have anxiety or panic attacks
N/A
16 of 20
F. Select which symptoms apply to you
I feel tired in the morning, even after a full night's sleep
I depend on caffeine to get through my day
My energy crashes in the afternoon
I crave salty or sweet food
I'm dizzy when I stand up too quickly
I have difficulty falling asleep and/or staying asleep
I have blood sugar issues
I get sick often and/or have a difficult time getting over infections
My muscles feel weaker
N/A
17 of 20
G. Select which symptoms apply to you.
I feel overwhelmed by stress
I have extra weight around my midsection
My body is tired at night, but my mind is going a mile a minute- "wired and tired"
I get a second wind at night that keeps me from falling asleep
I wake between 2 and 4am and can't go back to sleep
I get angry quickly or just feel on edge
I'm prone to injury and have difficulty healing
I have high blood pressure or a fast heart rate
I get shaky if I don't eat often
N/A
18 of 20
H. Select which symptoms apply to you
I have recurrent headaches
I find it difficult to break a sweat
I'm tired no matter how much I sleep
I have dry skin
I have joint or muscle pain
My periods are sporadic or occur more than 35 days apart
I'm losing hair (scalp, body, outer third of eyebrow)
I'm constipated often and need a stimulant (like caffeine) to get a bowel movement
I'm cold and/or have cold hands and feet
N/A
19 of 20
© 2025 Connected Habits Coaching. All rights reserved.
