Please select for EACH symptom you are currently experiencing
For symptoms that do not apply, please mark NONE.
Hot flashes, sweating (episodes of sweating) *
Heart Discomfort (heart skipping, heart racing, tightness)*
Sleep problems (Difficulty in falling asleep)*
Depressive mood (Feeling down, sad, on the verge of tears)*
Irritability (Feeling nervous, inner tension, feeling aggressive)*
Anxiety (Inner restlessness, feeling panicky)*
Physical & mental exhaustion (Impaired memory and/or focus)*
Sexual problems (Change in desire, activity, & satisfaction*
Bladder Problems (Difficulty in urinating or need to urinate)*
Dryness of vagina (Sensation of dryness or burning)*
Joint and muscular discomfort (Pain in the joints)*
Do you have cold hands and feet?*
Do you have daily bowel movements?*
Do you have gas, bloating or abdominal pain after eating?*
Please select your WEEKLY Activity Level based on this criteria Physical activity that accelerates heart rate / Breathlessness