Female Pre-HRT Questionnaire

Please fill out prior to purchase

Name*

First NameLast Name

Date*

MonthDayYear

Phone Number*

Area CodePhone Number

Email*

example@example.com

Select EACH symptom you are currently experiencing. Please mark only ONE box. For symptoms that do not apply, please mark NONE.*

Rows	None	Mild	Moderate	Severe	Extremely Severe
1. Hot flashes, sweating (episodes of sweating)
2. Heart discomfort (heart skipping, racing, chest tightness)
3. Sleep problems (difficulty in falling or staying asleep, waking up feeling tired)
4. Depressive mood (Feeling down, sadness, lack of drive, mood swings)
5. Irritability (Feeling aggressive, easily upset, moody)
6. Anxiety (feeling panicky)
7. Physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration)
8. Sexual problem (change in sexual desire, activity, and satisfaction)
9. Bladder Problems (difficulty in urinating, increased need to urinate, bladder incontinence)
10. Dryness of vagina (sensation of dryness or burning in the vagina, difficulty with sexual intercourse)
11. Joint and muscular discomfort (pain in the joints, rheumatoid complaints)

YesNo

0-1 day per week2-3 days per week3+ days per week