How old are you?
*
Under 35
35–44
45–54
55–64
65+
Which best describes your periods?
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Still regular
Becoming irregular
Stopped less than 12 months ago
Stopped more than 12 months ago
I've had a hysterectomy
I have a Mirena or am on contraception
In the past month, how much have you been bothered by each of the following?
Hot flushes
*
Not at all
A little
Quite a bit
A great deal
Night sweats
*
Not at all
A little
Quite a bit
A great deal
Difficulty falling asleep or staying asleep
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Not at all
A little
Quite a bit
A great deal
Feeling tired or lacking energy during the day
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Not at all
A little
Quite a bit
A great deal
Feeling tense, anxious or on edge
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Not at all
A little
Quite a bit
A great deal
Feeling low, flat or unlike yourself
*
Not at all
A little
Quite a bit
A great deal
Irritability or a shorter fuse than usual
*
Not at all
A little
Quite a bit
A great deal
Feeling tearful or emotionally unpredictable
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Not at all
A little
Quite a bit
A great deal
Difficulty concentrating or staying focused
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Not at all
A little
Quite a bit
A great deal
Memory lapses, or losing your words mid-sentence
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Not at all
A little
Quite a bit
A great deal
Joint pain, muscle aches or stiffness
*
Not at all
A little
Quite a bit
A great deal
Weight gain, especially around your middle
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Not at all
A little
Quite a bit
A great deal
Heart beating quickly or strongly
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Not at all
A little
Quite a bit
A great deal
Vaginal dryness, or discomfort or pain during sex
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Not at all
A little
Quite a bit
A great deal
Loss of interest in sex
*
Not at all
A little
Quite a bit
A great deal
Have you discussed these symptoms with a doctor before?
*
No, never
Yes, but I wasn't taken seriously
Yes, and I've tried treatment that didn't work
Yes, and I'm currently on treatment
First Name
*
Last Name
*
Phone
*
Email
*
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