Menopausal Symptoms Assessment
Please complete this assessment to help evaluate your menopausal symptoms and how they affect your daily life.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
Have you reached menopause (no menstrual period for 12 months or more)?
*
Yes
No
Not sure
How long has it been since your last menstrual period?
*
Please Select
Less than 6 months
6-12 months
1-3 years
More than 3 years
Not applicable
Please rate the frequency and severity of the following menopausal symptoms you have experienced in the past month.
*
Rows
Frequency
Severity
Hot flashes
Never
Rarely
Sometimes
Often
Always
None
Mild
Moderate
Severe
Very severe
Night sweats
Never
Rarely
Sometimes
Often
Always
None
Mild
Moderate
Severe
Very severe
Sleep disturbances
Never
Rarely
Sometimes
Often
Always
None
Mild
Moderate
Severe
Very severe
Mood changes (irritability, anxiety, depression)
Never
Rarely
Sometimes
Often
Always
None
Mild
Moderate
Severe
Very severe
Vaginal dryness/discomfort
Never
Rarely
Sometimes
Often
Always
None
Mild
Moderate
Severe
Very severe
Decreased libido
Never
Rarely
Sometimes
Often
Always
None
Mild
Moderate
Severe
Very severe
Fatigue
Never
Rarely
Sometimes
Often
Always
None
Mild
Moderate
Severe
Very severe
Difficulty concentrating or memory problems
Never
Rarely
Sometimes
Often
Always
None
Mild
Moderate
Severe
Very severe
How much do your menopausal symptoms interfere with your daily activities?
*
Not at all
1
2
3
4
5
6
7
8
9
Extremely
10
1 is Not at all, 10 is Extremely
Are you currently using any treatments or medications for menopausal symptoms?
*
Yes
No
If yes, please specify the treatments or medications you are using:
Please provide any additional comments or concerns regarding your menopausal symptoms:
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