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Are you having or have experienced night sweats or hot flashes?

Yes

No

Maybe

Are you having or have experienced mood changes or irritability?

Yes

No

Maybe

Are you having or have experienced vaginal dryness or painful sex?

Yes

No

Maybe

Are you having or have experienced loss of interest in sex?

Yes

No

Maybe

Are you having or have experienced weight gain or bloating?

Yes

No

Maybe

Are you having or have experienced memory loss or issues with mental clarity?

Yes

No

Maybe

Are you having or have experienced changes in sleeping habits?

Yes

No

Maybe

Are you having or have had hair loss or thinning of your hair?

Yes

No

Maybe

Are you having or have experienced urinary urgency, frequency, or recurrent urinary tract infections?

Yes

No

Maybe

Do you have a family history of (check all the apply)?

Osteoporosis

Heart Disease

Diabetes

Breast Cancer

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