Name (First & Last)*
Phone Number*
Email Address*
Hot Flashes*
Sweating (night sweats or excessive sweating)*
Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early ?*
Depressive mood (feeling down, sad, on the very 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, in sexual activity and/or orgasm and 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/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*