Skip to content
Tables

icon picker
Questions

Section A: Estrogen-Related Symptoms

For each statement, rate your experience over the past month on a scale of 0 to 4:
0 = Not at all, 1 = Rarely, 2 = Sometimes, 3 = Often, 4 = Very frequently

I experience hot flashes or night sweats.
I have experienced unexplained weight gain, especially around the abdomen.
I feel more fatigued than usual.
I've noticed increased vaginal dryness.
I'm having difficulty falling or staying asleep.
My mood feels consistently low or I feel depressed.
I've experienced memory issues or brain fog.
I notice more frequent urinary urgency or leakage.

Section B: Progesterone-Related Symptoms

I've experienced spotting between periods or unusual menstrual patterns (peri question)
I feel mood swings more frequently.
I've been feeling more irritable or have more nervous tension.
My allergies or asthma seem to have gotten worse.
I've noticed more frequent headaches or migraines.

Section C: Testosterone Related Symptoms

My libido or sexual desire has decreased noticeably.
My muscle strength seems to have diminished.
I feel less energetic overall.
My hair on the scalp has started to thin or fall out more than usual.



Hunger levels.
thyroid hormones, and adrenal hormones (like cortisol and DHEA)
Insulin

Section D: Adrenal Related Symptoms
I frequently feel stressed or overwhelmed.
I have difficulty getting up in the morning, even after a full night's sleep.
I experience energy crashes, especially in the afternoon.
I crave salty or sweet food




Section E: Emotional & Psychological Well-being
Do you often feel overwhelmed or find it hard to cope with daily stresses?
Have you noticed an increased feeling of detachment or disinterest in activities you used to enjoy?
Are you experiencing feelings of anxiety or panic without a clear reason?
Do you often feel isolated or avoid social interactions?
Are you having difficulty in accepting the physical and hormonal changes happening to your body?
Have you felt a loss of identity or purpose since entering menopause?
Do you frequently grapple with feelings of insecurity about aging?
This section would help in identifying women who might be struggling emotionally and psychologically, and appropriate support or counseling can be recommended.

Want to print your doc?
This is not the way.
Try clicking the ⋯ next to your doc name or using a keyboard shortcut (
CtrlP
) instead.