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*