Which of the following symptoms apply to you currently (in the last 2 weeks)? Please mark the appropriate box
    for each symptom. For symptoms that do not currently apply or no longer apply, mark “none”.

    Symptom Never Mild Moderate Severe Very Severe
    Hot flashes Never Mild Moderate Severe Very Severe
    Sweating (night sweats or increased episodes of sweating) Never Mild Moderate Severe Very Severe
    Sleep problems (difficulty falling asleep, sleeping through
    the night or waking up too early)    		 Never Mild Moderate Severe Very Severe
    Depressive mood (feeling down, sad, on the verge of tears,
    lack of drive)    		 Never Mild Moderate Severe Very Severe
    Irritability (mood swings, feeling aggressive, angers easily) Never Mild Moderate Severe Very Severe
    Anxiety (inner restlessness, feeling panicky, feeling nervous,
    inner tension)    		 Never Mild Moderate Severe Very Severe
    Physical exhaustion (general decrease in muscle strength
    or endurance, decrease in work performance, fatigue,
    lack of energy, stamina or motivation)    		 Never Mild Moderate Severe Very Severe
    Sexual problems (change in sexual desire, sexual activity,
    orgasm and/or satisfaction)    		 Never Mild Moderate Severe Very Severe
    Bladder problems (difficulty in urinating, increased
    need to urinate, incontinence)    		 Never Mild Moderate Severe Very Severe
    Vaginal symptoms (sensation of dryness or burning in vagina,
    difficulty with sexual intercourse)    		 Never Mild Moderate Severe Very Severe
    Joint and muscular symptoms (joint pain or swelling,
    muscle weakness, poor recovery after exercise)    		 Never Mild Moderate Severe Very Severe
    Difficulties with memory Never Mild Moderate Severe Very Severe
    Problems with thinking, concentrating or reasoning Never Mild Moderate Severe Very Severe
    Difficulty learning new things Never Mild Moderate Severe Very Severe
    Trouble thinking of the right word to describe persons, places
    or things when speaking    		 Never Mild Moderate Severe Very Severe
    Increase in frequency or intensity of headaches or migraines Never Mild Moderate Severe Very Severe
    Hair loss, thinning or change in texture of hair Never Mild Moderate Severe Very Severe
    Feel cold all the time or have cold hands or feet Never Mild Moderate Severe Very Severe
    Weight gain or difficulty losing weight despite diet and exercise Never Mild Moderate Severe Very Severe
    Dry or wrinkled skin Never Mild Moderate Severe Very Severe
    Family History No Yes
    Heart Disease No Yes
    Diabetes No Yes
    Osteoporosis No Yes
    Alzheimer's Disease No Yes
    Breast Cancer No Yes
    Personal History No If Yes, when
    Hysterectomy No Yes
    Breast Cancer No Yes
    Uterine Cancer No Yes
    Polycystic Ovaries No Yes
    Fibrocystic Breast No Yes
    Epilepsy No Yes
    Stroke No Yes


    Yes No

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