Menopause Symptoms Questionnaire
Please complete this questionnaire to help assess your menopause-related symptoms and their impact on your daily life.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
Current Menopausal Status
*
Pre-menopausal
Peri-menopausal (transitioning)
Post-menopausal
Not sure
Have you had a hysterectomy or oophorectomy (removal of ovaries)?
*
Yes
No
How often do you experience the following symptoms?
*
Rows
Never
Rarely
Sometimes
Often
Always
Hot flashes
1
2
3
4
5
Night sweats
6
7
8
9
10
Sleep disturbances
11
12
13
14
15
Mood swings/irritability
16
17
18
19
20
Vaginal dryness
21
22
23
24
25
Decreased libido
26
27
28
29
30
Joint pain/stiffness
31
32
33
34
35
Memory or concentration problems
36
37
38
39
40
How severe are your symptoms overall?
*
Not severe
1
2
3
4
5
6
7
8
9
Extremely severe
10
1 is Not severe, 10 is Extremely severe
Do your symptoms interfere with your daily activities?
*
Not at all
A little
Moderately
Severely
Have you used any treatments or remedies for menopause symptoms? (Select all that apply)
*
Hormone therapy
Herbal supplements
Lifestyle changes (diet, exercise, etc.)
No treatments used
Other
Please describe any other symptoms or concerns related to menopause (optional)
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