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Menopause Questionnaire

 

 

Menopause Questionnaire

 

 

 

Name: __________________________________________             Date ___________

 

Place an “X’ in front of the question if the answer is “yes” to any part of that question, otherwise leave blank.

 

Section A

 

  1. Are you experiencing hot flashes or night sweats, or both?             _____

 

  1. Are you feeling more depressed? Are you more withdrawn or isolated? _____

Do you fell periods of hopelessness? Do you feel apathetic?

 

  1. Do you feel a loss of energy? Do you feel more fatigued?             _____

 

  1. Do you feel less receptive to sex? Do you feel less sensual?

Do you feel that your sex drive has diminished?

 

  1. Are you having increased vaginal pain, dryness, or itching?             _____

 

  1. Are you experiencing insomnia, difficulty falling asleep, _____

or difficulty staying asleep?

 

  1. Are you having trouble with your memory? _____

Are you having more trouble remembering names?

Are you more forgetful?

 

  1. 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?

 

  1. Are you having trouble controlling your urine? _____

Do you have to go more often?

Do you spill urine when you cough or sneeze?

 

  1. 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?

 

Total for section A:                                                                                                  _______

 

 

Section B

 

  1. Are you having more aches and pain? Are you starting to get arthritis? _______

 

  1. Are you having more spotting or breakthrough bleeding?

Have you been told you have dysfunctional uterine bleeding?                      _______

 

  1. Do you seem to be getting more inflammations and swellings? _______

 

  1. Are your allergies or asthma getting worse,

or are you developing new allergies or asthma?                                            _______

 

  1. Do you seem to be having more twitches and spasms?                              _______

 

  1. Are you experiencing times of mental fogginess,

or trouble thinking clearly?                                                                              _______

 

  1. Are you having more mood swings? _______

 

  1. Do you feel more fatigued? Are you more tired in the morning? _______

 

  1. Are you more irritable/ Do you have more nervous tension? _______

 

  1. Are you experiencing more anxiety? Do you feel more anxious? _______

 

 

 

Total for Section B:                                                                                      _______

 

 

 

Section C

 

  1. Do you feel less motivated in general? Do you feel less assertive? _______

 

  1. 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?                                                                      _______

 

  1. Are you feeling less composed and in control? _______

 

  1. Are you less energetic? _______

 

  1. Are you anemic, or do you think you are anemic? _______

 

  1. Are you feeling more irritable? _______

 

  1. Do you have less muscle strength? Do you feel weaker?                         _______

 

  1. Are you having more trouble with mental skills requiring logic

and problem solving? Are you having trouble focusing

and maintaining your attention?                                                                      _______

 

  1. Is your memory weakening? Are you having more trouble

remembering things and events?                                                                   _______

 

  1. Do you feel more depressed? Is your mood low, less confident?

Are you feeling frightened or afraid?                                                              _______

 

 

Total for Section C:                                                                                      _______

 

 

 

 

Section D

 

  1. 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?                                                       _______

 

  1. Do you feel more depressed? _______

 

  1. Do you feel more fatigued in general? _______

 

  1. Are you having more headaches? _______

 

  1. Are you over 45 years old? _______

 

 

 

Total for Section D                                                                                       _______

 

 

 

Section E

 

  1. Does it seem as though your breasts are shrinking and sagging? _______

 

  1. Are you experiencing more confusion? _______

 

  1. Are you experiencing more morning fatigue? _______

 

  1. Do you cry more easily or more often? _______

 

  1. Are your hands or feet colder than usual? _______

 

 

 

Total for Section E:                                                                                      _______

 

 

 

Section F

 

  1. Is your libido less than It used to be? _______

 

  1. Is your pubic hair thinning?                                                             _______

 

  1. Do you feel less motivated, less assertive, and less confident?

Have you lost your competitive edge?                                                           _______

 

  1. Are you gaining more body fat? Do you feel less lean? _______

 

  1. Are you having more lower back pain or hip pain?

Do you feel more joint pain? Are you having more headaches?                   _______

 

 

Total for Section F:                                                                                                  ______

 

 

Section G

 

  1. Are you developing more facial hair? _______

 

  1. Is your voice changing and becoming deeper or more masculine? _______

 

  1. Are you having trouble tolerating sugars and carbohydrates? _______

 

  1. Are you developing or experiencing increased acne? _______

 

  1. Do you feel more hostile, angry, agitated, or aggressive? _______

 

 

Total for Section G:                                                                                                  _______

 

 

Section Totals Estrogen Deficiency Progesterone

Deficiency

Testosterone

Deficiency

Androgen Excess
A = A x 4 =      
B =   B x 5 =    
C =     C x 5 =  
D = D x 4 = D x 5 = D x 5 =  
E = E x 4 = E x 5 =    
F = F x 4 =   F x 5 =  
G =       G x 20 =
TOTALS: E = P = T = A =

 

 

 

E   P   T   A  

 

 

 

These letters can now be matched against data (including saliva test) to assess menopause type.

 

 

Estrogen Deficient if: E is 50 or more

 

Progesterone Deficient if: P is 50 or more

 

Testosterone Deficient if: T is 50 or more.

 

Testosteronedominant if: A is 60 or higher, and T score is 20 or less

 

 

 

Based on which formulations you need, you can discover your

Menopause Type by using the chart below

 

 

 

 

Adequate Estrogen & Adequate Progesterone Type 1 Type 2

TestoGain

Type 3

TestoQuench for Women

Deficient Estrogen & Adequate Progesterone Type 4

Estromend

Type 5

EstroMend

TestoGain

Type 6

EstroMend

TestoQuench for Women

Adequate Estrogen & Deficient Progesterone Type 7

ProgestoMend

Type 8

ProgestoMend

TestoGain

Type 9

ProgestoMend

TestoQuench for Women

Deficient Estrogen & Deficient Progesterone Type 10

EstroMend

ProgestoMend

Type 11

EstroMend

ProgestoMend

TestoGain

Type 12

EstroMend

ProgestoMend

TestoQuench for Women

 

 

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