Place an “X” for EACH symptom you are currently experiencing. Please mark only ONE box.
For symptoms that do not apply, please mark NONE.

    1. Hot flashes, sweating (episodes of sweating)

    2. Heart discomfort (awareness of heartbeat, heart skipping, tightness)

    3. Sleep problems (difficulty sleeping, waking early)

    4. Depressive mood (feeling down, mood swings)

    5. Irritability (inner tension, aggression)

    6. Anxiety (inner restlessness, feeling panicky)

    7. Physical and mental exhaustion (decrease in performance, memory)

    8. Sexual problems (desire, satisfaction)

    9. Bladder problems (frequent urination, incontinence)

    10. Dryness of vagina (dryness, burning, painful intercourse)

    11. Joint and muscular discomfort (pain, rheumatic complaints)

    Additional comments:

    Other Questions:

    Do you have cold hands and feet?

    Do you have daily bowel movements?

    Do you have gas, bloating or abdominal pain after eating?

    Weekly Activity Level:

    Your Name:

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