Female Symptoms Checklist Template

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SYMPTOMS CHECKLIST
DATE: ______ / ______ / _______
Lack of Estrogen
Lack of Progesterone
Hot Flashes
Headache
Shortness of Breath
Low Libido
Night Sweats
Anxiety
Sleep Disorders
Swollen Breasts
Vaginal Dryness
Moodiness
Dry Skin
Fuzzy Thinking
Anxiety
Depression
Mood Swings
Food Cravings
Headache
Irritability
Depression
Insomnia
Memory Loss
Cramps
Heart Palpitations
Emotional Swings
Yeast Infections
Painful Breasts
Vaginal Shrinkage
Weight Gain
Painful Intercourse
Bloating
Hair Loss/Dry Hair
Inability to Concentrate
Inability to Reach Orgasm
Asthma
Lack of Menstruation
Early Menstruation
Painful Joints
Acne
Abundance of Estrogen
Excess of Progesterone
Water Retention
Fatigue
Depression
Breast Swelling
Somnolence (Sleepiness)
Fibrocystic Breasts
Premenstrual-like Mood
Lack of Testosterone
Loss of Sex Drive
Heavy/irregular Menses
Low Libido/Sex Drive
Uterine Fibroids
Low Energy
Craving for Sweets
Loss of Muscle Tone
Weight Gain

Pitt Street Pharmacy
111 Pitt Street, Mt. Pleasant, SC 29464 p: 843 884 4051 f: 843 884 9117

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