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Patient Symptom Assessment Checklist for Women
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
Sweating (night sweats or increased episodes of sweating)
Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early)
Depressive mood (feeling down, sad, on the verge of tears, lack of drive)
Irritability (mood swings, feeling aggressive, angers easily)
Anxiety (inner restlessness, feeling panicky, feeling nervous, inner tension)
Physical exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation)
Sexual problems (change in sexual desire, sexual activity, orgasm and/or satisfaction)
Bladder problems (difficulty in urinating, increased need to urinate, incontinence)
Vaginal symptoms (sensation of dryness or burning in vagina, difficulty with sexual intercourse)
Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)
Difficulties with memory
Problems with thinking, concentrating or reasoning
Difficulty learning new things
Trouble thinking of the right word to describe persons, places or things when speaking
Increase in frequency or intensity of headaches or migraines
Hair loss, thinning or change in texture of hair
Feel cold all the time or have cold hands or feet
Weight gain or difficulty losing weight despite diet and exercise
Dry or wrinkled skin
Family History
No
Yes
Heart Disease
Diabetes
Osteoporosis
Alzheimer's Disease
Breast Cancer
Personal History
If Yes, when
Hysterectomy
Uterine Cancer
Polycystic Ovaries
Fibrocystic Breast
Epilepsy
Stroke
Age
Weight
Smoker YesNo
Last Menstrual Period
Birth Control
Thyroid Medication/dose
Current Hormone Replacement Therapy
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