Symptom Check-in — The Menopause Clinic
This check-in helps us track your symptoms over time while your treatment is adjusting. It is not monitored in real time — if you have urgent or emergency symptoms, please seek care right away through urgent care, the ER, or your primary care provider
Name
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What is the reason for this check-in? Want your provider to see this? Select the second option
*
I need a refill (within the next 2 weeks)
I have a concern, question, or would like my provider to review this
Routine only — no refill needed and no questions or concerns (filling this out to track my progress only)
Date you started or most recently changed your estrogen dose
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Since your last check-in, would you say things are overall:
*
Better
Same
Worse
Just starting / first check-in
Hot flashes / Night sweats
*
Not at all
Mild
Moderate
Severe
Trouble falling asleep
*
Not at all
Mild
Moderate
Severe
Trouble staying asleep
*
Not at all
Mild
Moderate
Severe
Brain fog / Trouble focusing / Finding words
*
Not at all
Mild
Moderate
Severe
Mood swings / Irritability
*
Not at all
Mild
Moderate
Severe
Low energy / Fatigue
*
Not at all
Mild
Moderate
Severe
Joint pain
*
Not at all
Mild
Moderate
Severe
Vaginal dryness or pain with sex
*
Not at all
Mild
Moderate
Severe
Urinary symptoms (leaking, urgency, burning, UTIs)
*
Not at all
Mild
Moderate
Severe
Low libido/Low sex drive
Not at all
Mild
Moderate
Severe
Breast tenderness
*
Yes
No
When does it happen? (click ALL that apply)
Every day or most days
Started when I began estrogen
Started when I began progesterone
Started after a recent dose change
Only some days of the month (comes and goes with my cycle)
How long has this been going on?
Less than 2 weeks
2–6 weeks
Type option 3
More than 6 weeks
Bloating
*
Yes
No
When does it happen? (click ALL that apply)
Every day or most days
Started when I began estrogen
Started when I began progesterone
Started after a recent dose change
Only some days of the month (comes and goes with my cycle)
How long has this been going on?
Less than 2 weeks
2–6 weeks
Type option 3
More than 6 weeks
If you use an estrogen patch, have you noticed any issues with it?
*
No issues — sticking well
Mild skin irritation
Patch not sticking flat (wrinkling or lifting)
Patch crinkling or bunching
Not applicable — I don't use a patch
Except for your regular period (if having one), have you had any vaginal bleeding since your last check-in?
*
Yes
No
Except for your regular period (if having one), have you had any vaginal bleeding since your last check-in? If yes, Light spotting or light-mild bleeding or heavy bleeding
Light spotting
Light-mild bleeding
Heavy bleeding --Soaking through a pad or tampon in an hour or less, passing large clots (quarter-sized or bigger), or bleeding that's significantly heavier than your normal period
Are there any new side effects or changes you've noticed? Anything you'd like your provider to know?
Submit
Should be Empty: