Women’s Health Questionnaire – Natural Health & Wellness Center

Do you have a lack of energy?*

Do you feel stressed? *

Do you experience restless sleep or insomnia?*

Do you feel sad and/or grumpy?*

Do you have mood swings?*

Do you have difficulty concentrating?*

Are you forgetful?*

Do you have premenstrual symptoms? *

Do you have pre- or postmenopausal hot flashes and/or night sweats?*

Have you noticed a decrease in your sex drive?*

Have you recently gained weight?*

Are you overweight?*

Have you lost height?*

Name*

First Last

Phone*

Email*