Your Hormone Blueprint Questionnaire

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
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)
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
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

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
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
Dry, itchy, or rough skin

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____________

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HORMONE INTELLIGENCE

HORMONE BLUEPRINT QUESTIONNAIRE

Check all boxes that relate to you in each section.

Pattern 1: High Estrogen

Pattern 2: Low Estrogen

Irregular or absent periods

www.avivaromm.com ©Aviva Romm MD 2021

Irregular menstrual cycles

Pattern 4: High Testosterone

Pattern 5: Low Testosterone

www.avivaromm.com ©Aviva Romm MD 2021

Chronic stress, overwhelm Low (or no) sex drive

Pattern 7: Low Thyroid Hormone

Sluggishness, fatigue, zero energy

www.avivaromm.com ©Aviva Romm MD 2021

High blood sugar Frequent thirst, frequent urination

www.avivaromm.com ©Aviva Romm MD 2021

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