Have they been getting shorter or more unpredictable? *

Yes

No

Have friends or family mentioned that you’ve been more irritable lately? *

Yes

No

Has your interest in sex decreased, or do you experience dryness or discomfort during intercourse? *

Yes

No

Are you feeling more tired or less energetic than usual? *

Yes

No

Have you noticed changes in your body shape, or are you finding it harder to manage your weight? *

Yes

No

Are you dealing with hair thinning or changes in your skin like dryness? *

Yes

No

Do you have trouble falling asleep or staying asleep through the night? *

Yes

No

Have you noticed that you’re forgetting things more often? *

Yes

No

Are you having more frequent headaches or migraines? *

Yes

No

Do you feel the need to pee more often or urgently, or have you experienced any bladder leaks? *

Yes

No

Do you get hot flashes during the day or wake up at night drenched in sweat? *

Yes

No

First Name

Last Name

Phone *