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Endocrine Questionnaire Part B
Endocrine Questionnaire Part B
By
HNHadmin
December 10, 2018
October 16, 2020
Welcome to your Endocrine Questionnaire Part B
Name:
Email:
Phone Number:
I have patches of hair loss
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1
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3
4
I have a very pale complexion
0
1
2
3
4
I sunburn easily
0
1
2
3
4
I often have memory loss
0
1
2
3
4
I'm stressed out / I'm facing many difficulties
0
1
2
3
4
My blood pressure has dropped
0
1
2
3
4
My friends tell me I look thinner
0
1
2
3
4
I urinate too many times in a day
0
1
2
3
4
I crave salty foods
0
1
2
3
4
My blood pressure is low
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1
2
3
4
I feel dizzy when I stand up
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1
2
3
4
I feel much better lying down than standing up
0
1
2
3
4
I have vertebral fractures (crushes) - compression fractures in my spine
0
1
2
3
4
I've lost height
0
1
2
3
4
My back hurts
0
1
2
3
4
I'm very sensitive to pain
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1
2
3
4
I have thyroid problems (goiter, thyroid insufficiency, radiation has been applied to this area)
0
1
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3
4
I have a particularly pale complexion
0
1
2
3
4
Prolonged physical effort leaves me breathless
0
1
2
3
4
I am anaemic (diagnosed by blood test)
0
1
2
3
4
I don't have a very good sense of 'well-being'
0
1
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3
4
My blood test shows an increased Blood Uric Nitrogen
0
1
2
3
4
I crave sugar and sweets, and eat a lot of them
0
1
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3
4
I'm always thirsty
0
1
2
3
4
I urinate a lot during the day as well as at night
0
1
2
3
4
I have difficulty healing
0
1
2
3
4
My stomach and buttocks are skinny
0
1
2
3
4
I look older than I am
0
1
2
3
4
I have trouble falling asleep at night
0
1
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3
4
I wake up during the night...
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3
4
... and I can't get back to sleep
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1
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3
4
My mind is busy with anxious thoughts while I'm trying to fall asleep
0
1
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3
4
My feet are too hot at night
0
1
2
3
4
I have memory loss
0
1
2
3
4
My joints hurt (fingers, wrists, elbows, feet, ankles, knees)
0
1
2
3
4
I'm feeling a bit drained and I have a hard time handling stress
0
1
2
3
4
I don't see colours as brightly as before
0
1
2
3
4
I have lost interest in art; I don't appreciate art as much anymore
0
1
2
3
4
I don't have much hair under my arms or in the pubic area
0
1
2
3
4
My muscles are flabby
0
1
2
3
4
I have abundant, light-coloured urine during the day
0
1
2
3
4
I have low blood pressure
0
1
2
3
4
I crave salty foods
0
1
2
3
4
I'm thirsty at night
0
1
2
3
4
I get up at night to urinate
0
1
2
3
4
I bleed a lot when I get hurt
0
1
2
3
4
I have a hard time thinking straight
0
1
2
3
4
Time is Up!
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Endocrine Questionnaire Part A
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