Menopausal Symptom Checklist
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1Menopausal Symptom Checklist
Do you experience any of the following symptoms and associate them with menopause?
Symptoms
Never
Rarely
Frequently
Daily
Multiple
Experienced
Experienced
Experienced
Experience
times/day
Hot flashes
Night sweats
Profuse sweating
with hot flashes
Mood changes
Decreased memory
Difficulty
concentrating
Sleep disruption
Fatigue
Irritability
Anxiety/nervousness
Depression
Headaches
Decreased libido
Vaginal dryness
Incontinence
Urinary tract
Infections
Palpitations
Nausea
Dry skin
Dry eyes
Joint pain
Irregular menses
Heavy bleeding
Light bleeding or
spotting
Hair loss
Facial hair
Acne
Weight gain
Do you experience any other symptoms that are not listed? _______________________________
______________________________________________________________________________
Are you currently on any type of Hormonal Replacement Therapy (HRT)? Yes
No
If so, what type, and what dosage are you currently taking: _______________________________
Have you had a hysterectomy?
Yes
No
If so, do you still have your ovaries?
Yes
No
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Parent category: Life