Dayton Ear, Nose
& Throat Surgeons, Inc.

John H. Boyles Jr., M.D.         James J. Howard, M.D.         William E. Rogers, M.D.

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Hormone Questionnaire

Please read each question carefully. Choose the appropriate answer for each question and when you are finished, click the Submit button at the bottom of the page.

1. Do you experience fatigue or muscle weakness? Yes   No
2. Do you have difficulty losing weight? Yes   No
3. Are you experiencing hair loss or thinning of your hair, eyebrows, or eyelashes? Yes   No
4. Do you have a slow pulse or low blood pressure? Yes   No
5. Are you sensitive to the cold and do your hands and feet feel cold? Yes   No
6. Do you feel that you are retaining fluids? Yes   No
7. Do you have voice changes or hoarseness? Yes   No
8. Do you have elevated cholesterol? Yes   No

For Women Only
1. Do you have hot flashes or night sweats? Yes   No
2. Do you have vaginal dryness? Yes   No
3. Are you depressed or having unexplained mood swings? Yes   No
4. Do you have difficulty sleeping? Yes   No
5. Have you lost interest in sex? Yes   No
6. Have your periods ceased? Yes   No
7. Have you experienced a decline in your mental sharpness? Yes   No

For Men Only
1. Do you have chronic fatigue? Yes   No
2. Do you have unexplained weight gain? Yes   No
3. Have you lost your sex drive? Yes   No
4. Have you lost muscle mass? Yes   No
5. Do you have loss of memory and brain function? Yes   No

Submit Results