Menopause Questionnaire APP

Name*
Email
Phone
Date
Date Format: MM slash DD slash YYYY
Section A
1. 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 Are you more withdrawn or isolated?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