Date of Birth:


City/Town:                                                      State:                            Postcode:

Tel number:                                                                                 Mobile:

Email Address:

Height:                                          Weight:

Your Doctor’s Name:


Do you Smoke:                                      How often and How much:

Did you ever smoke:                                 When did you give up:

Do you drink Alcohol:                            How often and How much:

Do you have any allergies:

Marital Status:                                    No. of Pregnancies:                  No.  Miscarriages:

What Work do you do:

What operations have you had:

Medical conditions:

What medicines are you on:

Family history: Any important illness/diseases in the family:

When last did you have:  Mammogram:                          Pap Test:                            BP check:

Hormones previously taken:

Date of last period:

Menopause Rating scale.(Use in preference to one below)

Hormone Symptom Chart:       None               Mild              Moderate             Severe





Mood Swings:



Hot Flushes/Night Sweats:


Insomnia/Sleep disturbance:

Sore Joints:

Urine leaks when straining:

Loss of Sex Drive:

Painful sexual intercourse:

Loss of enjoyment in Sex:  If Yes, then please do the Decreased_Sexual_Desire_Screener_DSDS_Female_Sexual_Dysfunction_Tool

Fluid Retention:

Breast pain/Tenderness:

Hair loss:

Weight Gain:

Excess facial/body hair:

Skin Crawling/Itchy:

Please Print and bring with you when you see Dr Holloway

  1. Print it out, then scan it after completing it. Or fax it to me.

  2. How do I compete the female hormone check list on the website as it won’t let me type on it

  3. This does not sound hormonal, so i don’t think it would help. I rarely use hormones in young women ans their systems are still maturing and tampering with their hormones can do more harm than good. I really don’t know what advice to give you for this debilitating problem.

  4. Jennie Brosnan

    Hi Dr Holloway, one of your patients has advised that I contact you regarding my 18 year old daughter. We think she may have a hormone imbalance. She seems to be having very similar symptoms to my friend who is in hard menopause except that Jazmin has been having blackouts since August 2016 and then they progressed to blackouts with seizures since November 2016. She now has multiple seizures per day and has been hospitalised twice. The EEGs and ECGs have all been normal so they have diagnosed her with functional neurological disorder and put on Endep for the servere headache that she has after a blackout/seizure. She has put on a lot of weight since these started which looks like she is inflamed or holding a lot of fluid. She constantly gets uncontrollably itchy all over, with body aches, insomnia and uncontrollable sweating. I think she also has vertigo before she blacks out.
    This has stopped her life in its tracks. She is unable to drive, go out at night (as they usually start in the afternoon) and she cannot work or take public transport.
    She had an implanon inserted about 18 months ago due to extreme periods and migraines since she was 9 and since then she has been put on fluoxetine for anxiety and OCD but has since stopped taking it as we thought it maybe causing the episodes. I really think this may all be caused from a hormonal imbalance and would love your feedback and thoughts on this. We are at our wits end and trying anything to help her. We are in Brisbane North so are able to come and see you if you feel you could help her.
    I hope to hear back from you soon.
    Kind regards
    Jennie Brosnan

  5. Have you had your hormones tested- oestrogen, testosterone, DHEA and progesterone?

  6. LDN may benefit you. Read the information re LDN on my web-site.

  7. Dr Holloway
    I have just turned 60. I have hashimotos and have been taking oroxine for about 30 odd years now. At the age of about 52 I had sore muscles and low libido. I saw a menopause specialist in Buderim and she inserted a testosterone pellet under my skin in my stomach but they soon were taken off the market. She prescribed men’s testosterone gel which is working fine. I did have some relief from muscle soreness. Approximately 3 years ago I was diagnosed with Fybromyalgia and is getting worse.I can’t take any of the medications for it due to side effects. I have depression, fluid retention, gord,and sleep apnea and struggle with my weight. What are your thoughts please?

  8. Hi Dr Holloway. I live on the Sunshine Coast and am looking for a doctor that can help me as I’ve gotten no where for the last 5/6 years with my current GP who I’m sure thinks I’m just a complete weirdo/ winger/hypercon ..
    Basically I have had severe and I mean severe fatigue to the point where I have to pull over when driving for more than half an hour. Can fall asleep anywhere if I don’t try really hard to stay awake. I’m 32 years old. I have literally had every test under the sun done.. Well I think I have! I’ve even had a sleep study done which showed slight sleep apnea but not bad enough for them to treat.
    In all the testing over the last 10 or so years, they have found- pernicious anemia due to non gut absorption, diagnosed fibromyalgia, chronic fatigue syndrome, restless leg syndrome, ?depression, lactose intolerant … But there HAS to be a reason!!!!
    I have been to naturopaths, chiropractors, osteopaths, psychologists etc etc and I am just about at the point of breakdown. Yes I’m a single mum, yes I’m a nurse and work shift work, yes I have a busy life; but I can’t possibly go on like this… Every day is a struggle. I try my best to suffer in silence. I still exercise and try and get to the gym 2-3 times a week. But boy is it hard work. I used to be the sportiest, fittest and energetic person going. Now I struggle to survive a day without a nap! I have changed my diet- no processed sugar, no gluten, no dairy, take every multivitamin under the sun…. But nothing is helping!!
    I have my thyroid function checked ALL the time thinking it just has to be hypothyroidism as I have SO many of the synptoms- but it always comes back as being fine.. My iron is fine, my B12 if fine… I have terrible cystic acne that cleared up beautifully on roaccutane but since stopping it 2 years ago, it’s all back 😦 please can you help? Or recommend an endocrinologist/ hormone specialist on the Sunshine Coast (that won’t cost me the earth 😝

  9. Most younger women undergo many hormonal and other changes. As your hormones are still undergoing change under the age of about 25, I prefer not to interfere with them. Better to let nature take its course. However, your GP can help with the other issues you are undergoing.

  10. Hi Dr Holloway,
    I am 22 years old and experiencing some symptoms that i feel could be a major hormone imbalance but just wanted to ask incase it may be normal for a 22 year old female to go through, the past few months i have been experiencing severe mood swings, anxiety, breaking out of pimples on the chin, loss of libido, lack of motivation and brain fogginess (wanting to do something but feeling to frustrated to do so) and loss of excitement for things id usually be very excited for and feeling down on my outlook on life and just stuck and just not my usual self would love to know your oppinion. Thank you

  11. I have made an appointment with my GP tomorrow to request new bloods and obtain copies from 2 years ago. What other information do you require from me to see if you may be able to help

  12. I may be able to help, but without further details cannot be sure.

  13. 2 years ago I was suspected of having a pituitary tumor but after MRIs, lots of blood tests I was told it was extreme levels of cortisol causing anxiety, panic attacks, depression etc. 2 years on and no further treatment I am still suffering in silence. However I have just left an abusive relationship and after lots of reading realize this is probably the root of my health issues. I believe I have suffered with prolonged adrenal stress causing hormonal imbalance. Are you able to help with rectifying these hormonal issues?

  14. Susanne Bosward

    Thankyou so much for your email. can you recommend someone in cooroy/ noosa area.

  15. The menopause centre have had various problems, so I don’t encourage people to go there. Best to see someone local who can help you – there are doctors on the sunshine coast who use Bioidentical HRT.

  16. Dear dr Holloway, Going through menopause centre in sydney. Been doing so for 4 months. Found out oestrogen cream was full of chemicals and progesterone troche in PEG base. Have just swapped to gelatin troche 75mg and half e2 .38mg which seems unusual. Still anxious, hopeless and severely depressed with flushing. Broke out in hives while on other
    Hormones. Been on these for a week. Im hoping just chemicals caused hives. Have you ever heard of this. If so how long will it take for them to disappear. Feel so disfigured. Dry mouth and skin also. Have u heard of success with menopause centre. I am concerned that they even considered addin g the chemicals. I live in Eumundi on sunshine coast. Im desperate. Ive been mucked around so much and still feel terrible.
    Sincerely Susanne

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