Hormone Health Quiz Question Template for Functional Medicine
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Hormone Health Quiz Question Template for Functional Medicine
A ready-to-use set of 8 hormone health assessment questions designed for functional medicine practitioners. This template evaluates cycle regularity, PMS severity, hormone-stress interactions, and lifestyle factors affecting hormonal balance. Patient responses map to three clinical archetypes: Estrogen Dominance, Stress-Adaptive Hormone Shift, and Low-Androgen or Perimenopausal Transition.
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How to Use This Template
Download and Print
Click the "Download as PDF" button above and save the template to your computer. Print copies for your practice or keep a digital reference.
Copy Into Your Assessment Tool
Copy the 8 questions below into any quiz builder, form tool, or assessment platform. Each question includes multiple-choice options and maps to specific clinical archetypes. Modify as needed to fit your clinical approach.
Or Automate With Brevlix
Instead of copying questions manually, Brevlix deploys this hormone health assessment on your website in minutes. Scoring, archetype mapping, and patient report generation are handled automatically. Customize your branding and go live.
Template Content
Q1: How would you describe your menstrual cycle?
☐ Regular (predictable within 1-2 days)
☐ Somewhat irregular (varies by 3-7 days)
☐ Very irregular (hard to predict)
☐ No current cycle (postmenopausal, amenorrhea, etc.)
☐ Not sure / haven't tracked
Q2: Which PMS symptoms do you experience? (check all that apply)
☐ Mood swings
☐ Breast tenderness
☐ Bloating
☐ Cramps
☐ Headaches
☐ Fatigue
☐ Food cravings
☐ None — I don't experience PMS
Q3: How would you rate your PMS severity?
☐ Mild — barely noticeable
☐ Moderate — affects daily activities somewhat
☐ Severe — significantly disruptive
☐ No PMS
Q4: Have you noticed your hormone symptoms change with stress?
☐ Yes — symptoms worsen with high stress
☐ No change with stress levels
☐ Not sure
Q5: How long is your typical menstrual cycle?
☐ Shorter than 21 days
☐ 21-35 days
☐ Longer than 35 days
☐ Varies widely, hard to track
Q6: Do you experience mid-cycle pain?
☐ Yes
☐ No
☐ Not sure
Q7: Have you been diagnosed with any of the following? (check all that apply)
☐ PCOS
☐ Endometriosis
☐ Fibroids
☐ None of these
Q8: Rate your overall hormonal wellness on a scale of 1-5.
1 — Poor
2
3 — Average
4
5 — Excellent
Clinical Archetypes:
Click the button to open your browser's print dialog. Select "Save as PDF" as the destination to download.
Deploy This Hormone Health Assessment on Your Website
Brevlix turns this template into a live, interactive assessment. Patients complete it on your website, responses are scored automatically, and they receive an instant personalized health archetype report — all in about 3 minutes.
Start Free →Frequently Asked Questions
What does the hormone health quiz template assess?
This template evaluates menstrual cycle regularity, PMS type and severity, hormone-stress interactions, cycle length, mid-cycle pain, diagnosed hormonal conditions (PCOS, endometriosis, fibroids), and overall hormonal wellness. The 8 questions differentiate between Estrogen Dominance, Stress-Adaptive Hormone Shift, and Low-Androgen or Perimenopausal Transition.
Can this template be used for perimenopausal patients?
Yes. The template includes response options for patients with no current cycle (postmenopausal, amenorrhea) and maps irregular cycle patterns to the Low-Androgen or Perimenopausal Transition archetype. It is designed to be relevant across reproductive life stages.
How does stress affect the hormone archetype mapping?
Question 4 specifically captures whether hormone symptoms worsen with stress. This is a key differentiator: patients whose symptoms are stress-responsive map toward the Stress-Adaptive Hormone Shift archetype, which involves HPA-axis and cortisol interactions with sex hormones.
How do I use this template in my practice?
Download the PDF, copy the questions into your existing quiz tool, or deploy through Brevlix for an automated solution. Use it as a pre-appointment screening tool to gather structured hormonal health data before the first consultation.