The Mamichie 3R Method™ Hormonal Integrity Index

This tracker is designed to help you monitor and reflect on your weekly symptoms with clarity and structure. By scoring each symptom and noting key reflections, you’re not just collecting data - you’re tracking symptoms to help us identify patterns and hormone fluctuations, tailor interventions more effectively, and celebrate progress even in small shifts.

Rate each symptom and take a moment to reflect on your week. Your input will help us finetune your support and ensure your progress is both measurable and meaningful.

First name

Last name

Phone

Date of Birth

Use the severity scale key below to rate the severity level of the symptoms stated below:

0-3 = Mild: Symptom is present but manageable

4-6 = Moderate: Affects mood or function; needs attention

7-10 = Severe: Significantly disrupts life; clinical review advised

* Hot Flushes

* Night Sweats

* Fatigue

* Brain Fog

* Mood Swings

* Bloating

* Anxiety

* Sleep Quality

* Libido

* Menstrual Cycle Regularity

What was your most difficult symptom this week?

What helped you feel more balanced?

Can you recollect any lifestyle factors that influenced your symptoms?

* I understand that Mamichie Healthcare Limited is committed to protecting my personal information in accordance to UK GDPR laws and I understand that by submitting this form, I consent to Mamichie Healthcare Limited collecting and securely processing the information I’ve provided in accordance with its Privacy Policy to support my care and ongoing clinical review.