Perimenopause Symptom Checklist
Assess and track your perimenopause symptoms to better understand your experience.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
How would you describe your current menstrual cycle?
*
Regular
Irregular
Stopped (no period for over 12 months)
Other
Please rate the severity of the following symptoms experienced in the past month:
*
Rows
Not at all
Mild
Moderate
Severe
Hot flashes
1
2
3
4
Night sweats
5
6
7
8
Sleep disturbances
9
10
11
12
Mood swings or irritability
13
14
15
16
Vaginal dryness
17
18
19
20
Decreased libido
21
22
23
24
Fatigue or low energy
25
26
27
28
Memory or concentration issues
29
30
31
32
Joint or muscle aches
33
34
35
36
Weight changes
37
38
39
40
Have you noticed any of the following changes? (Select all that apply)
Increased anxiety
Palpitations
Headaches
Hair thinning
Other
How would you rate your overall quality of life in the past month?
*
Very poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very poor, 10 is Excellent
Are you currently taking any hormone therapy or medications for menopause symptoms?
*
Yes
No
If yes, please specify the medications or therapies you are using:
Is there anything else about your symptoms or experience you would like to share?
Submit Checklist
Should be Empty: