Assessment Form Step 1 of 2 50% Name(Required) First Last Email(Required) Phone(Required) Which of the following symptoms apply to you currently (in the last month)? Please mark the appropriate answer for each symptoms severity. For symptoms that do not currently apply or no longer apply , mark "none".Hot Flashes(Required) None Mild Moderate Severe Very Severe Sweating (night sweats or increased episodes of sweating)(Required) None Mild Moderate Severe Very Severe Sleep problems (difficulty falling asleep, sleeping through the night, or waking up too early)(Required) None Mild Moderate Severe Very Severe Depressive mood (feeling down, sad, on the verge of tears, lack of drive)(Required) None Mild Moderate Severe Very Severe Irritability (mood swings, feeling aggressive, angers easily)(Required) None Mild Moderate Severe Very Severe Anxiety (inner restlessness, feeling panicky, feeling nervous, inner tension)(Required) None Mild Moderate Severe Very Severe Physical exhaustion (fatigue, lack of energy, stamina or motivation, general decrease in muscle strength or endurance, decrease in work performance)(Required) None Mild Moderate Severe Very Severe Sexual problems (decrease in sexual desire, decrease in sexual activity, orgasm and/or satisfaction)(Required) None Mild Moderate Severe Very Severe Bladder problems (difficulty urinating, increased need to urinate, incontinence)(Required) None Mild Moderate Severe Very Severe Vaginal symptoms (sensation of dryness or burning in the vagina, difficulty or pain with sexual intercourse)(Required) None Mild Moderate Severe Very Severe Muscle and/or joint symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)(Required) None Mild Moderate Severe Very Severe Difficulties with memory(Required) None Mild Moderate Severe Very Severe Problems with thinking, concentrating or reasoning(Required) None Mild Moderate Severe Very Severe Difficulty learning new things(Required) None Mild Moderate Severe Very Severe Trouble thinking of the right word to describe persons, places or things when speaking(Required) None Mild Moderate Severe Very Severe Increase in frequency or intensity of headaches or migraines(Required) None Mild Moderate Severe Very Severe Hair loss, thinning, or change in texture of hair(Required) None Mild Moderate Severe Very Severe Feel cold all the time or have cold hands or feet(Required) None Mild Moderate Severe Very Severe Weight gain or difficulty losing weight despite diet and exercise(Required) None Mild Moderate Severe Very Severe Dry or wrinkled skin(Required) None Mild Moderate Severe Very Severe This field is hidden when viewing the formSymptom Severity ScoreThis field is hidden when viewing the formPDF
