Step 1 of 7 14% Name*Email PhoneDate Date Format: MM slash DD slash YYYY Section A1. Are you experiencing hot flashes or night sweats, or both?* YES NO 2. Are you feeling more depressed? Are you more withdrawn or isolated? Do you fell periods of hopelessness? Do you feel apathetic?* YES NO 3. Do you feel a loss of energy? Do you feel more fatigued?* YES NO 4. Do you feel less receptive to sex? Do you feel less sensual? Do you feel that your sex drive has diminished?* YES NO 5. Are you having increased vaginal pain, dryness, or itching?* YES NO 6.Are you experiencing insomnia, difficulty falling asleep, or difficulty staying asleep?* YES NO 7. Are you having trouble with your memory? Are you having more trouble remembering names? Are you more forgetful?* YES NO 8.Is your mood low, less upbeat, less positive, or less outgoing? Are you having less "good moods" and times of joy? Do you find yourself caring less about things that used to matter to you?* YES NO 9.Are you having trouble controlling your urine? Do you have to go more often? Do you spill urine when you cough or sneeze?* YES NO 10. Do you feel as if your perception is weakening, that it takes you longer to notice things? Are you having trouble thinking of the right word when speaking or writing? Do you feel your mental skills are diminishing?* YES NO Section B1. Are you having more aches and pain? Are you starting to get arthritis?* YES NO 2. Are you having more spotting or breakthrough bleeding? Have you been told you have dysfunctional uterine bleeding?* YES NO 3. Do you seem to be getting more inflammations and swellings? _______* YES NO 4. Are your allergies or asthma getting worse, or are you developing new allergies or asthma?* YES NO 5. Do you seem to be having more twitches and spasms?* YES NO 6. Are you experiencing times of mental fogginess, or trouble thinking clearly?* YES NO 7. Are you having more mood swings?* YES NO 8. Do you feel more fatigued? Are you more tired in the morning?* YES NO 9. Are you more irritable/ Do you have more nervous tension?* YES NO 10. Are you experiencing more anxiety? Do you feel more anxious?* YES NO Section C1. Do you feel less motivated in general? Do you feel less assertive?* YES NO 2. Has your libido lessened? Are you having fewer sexual fantasies or less desire? Are you less likely to become sexually aroused? Are you less pleased with sex?* YES NO 3. Are you feeling less composed and in control?* YES NO 4. Are you less energetic?* YES NO 5. Are you anemic, or do you think you are anemic?* YES NO 6. Are you feeling more irritable?* YES NO 7. Do you have less muscle strength? Do you feel weaker?* YES NO 8. Are you having more trouble with mental skills requiring logic and problem solving? Are you having trouble focusing and maintaining your attention?* YES NO 9. Is your memory weakening? Are you having more trouble remembering things and events?* YES NO 10. Do you feel more depressed? Is your mood low, less confident? Are you feeling frightened or afraid?* YES NO Section D1. Are you noticing more wrinkles around your mouth and eyes? Is the skin tone on your arms, legs, or hands poor? Has the skin lost its firmness or fullness?* YES NO 2. Do you feel more depressed? Has the skin lost its firmness or fullness?* YES NO 3. Do you feel more fatigued in general?* YES NO 4. Are you having more headaches?* YES NO 5. Are you over 45 years old?* YES NO Section D 1. Does it seem as though your breasts are shrinking and sagging?* YES NO 2. Are you experiencing more confusion?* YES NO 3. Are you experiencing more morning fatigue?* YES NO 4. Do you cry more easily or more often?* YES NO 5. Are your hands or feet colder than usual?* YES NO Section F1. Is your libido less than It used to be?* YES NO 2. Is your pubic hair thinning?* YES NO 3. Do you feel less motivated, less assertive, and less confident? Have you lost your competitive edge?* YES NO 4. Are you gaining more body fat? Do you feel less lean?* YES NO 5. Are you having more lower back pain or hip pain? Do you feel more joint pain? Are you having more headaches?* YES NO Section G1. Are you developing more facial hair?* YES NO 2. Is your voice changing and becoming deeper or more masculine?* YES NO 3. Are you having trouble tolerating sugars and carbohydrates?* YES NO 4. Are you developing or experiencing increased acne?* YES NO 5. Do you feel more hostile, angry, agitated, or aggressive?* YES NO
