Menopause symptoms checklist
Please tick and rate your symptoms. Print and take it with you when you go to see your doctor
General symptoms
Low mood
Mild
Moderate
Severe
Mood swings
Mild
Moderate
Severe
Anxiety
Mild
Moderate
Severe
Panic attacks
Mild
Moderate
Severe
Irritability
Mild
Moderate
Severe
Tearfulness
Mild
Moderate
Severe
Loss of joy (anhedonia)
Mild
Moderate
Severe
Loss of confidence
Mild
Moderate
Severe
Memory problems
Mild
Moderate
Severe
Brain fog
Mild
Moderate
Severe
Poor concentration
Mild
Moderate
Severe
Loss of energy/fatigue
Mild
Moderate
Severe
Insomnia/Sleep problems
Mild
Moderate
Severe
Night sweats
Mild
Moderate
Severe
Hot flushes
Mild
Moderate
Severe
Headaches/migraines
Mild
Moderate
Severe
Heart palpitations
Mild
Moderate
Severe
Joint or muscle pains
Mild
Moderate
Severe
Dry mouth
Mild
Moderate
Severe
Dry eyes
Mild
Moderate
Severe
Itchy skin/a feeling like ants are crawling under your skin (formication)
Mild
Moderate
Severe
Changes to periods (lighter, heavier, more/less frequent)
Mild
Moderate
Severe
Weight gain
Mild
Moderate
Severe
Dizziness/light headedness
Mild
Moderate
Severe
Ringing in the ears (tinnitus)
Mild
Moderate
Severe
Restless legs
Mild
Moderate
Severe
Hair loss/thinning
Mild
Moderate
Severe
Low libido
Mild
Moderate
Severe
Increased allergies
Mild
Moderate
Severe
Bloating/gas/reflux
Mild
Moderate
Severe
Burning tongue
Mild
Moderate
Severe
Are there any further details relating to the above symptoms would like to share?
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GSM symptoms
Vaginal dryness
Mild
Moderate
Severe
Pain during or after sex
Mild
Moderate
Severe
Bleeding after sex
Mild
Moderate
Severe
Vulval pain/itching /irritation/burning (external)
Mild
Moderate
Severe
Skin splitting or tearing
Mild
Moderate
Severe
Labia shrinking
Mild
Moderate
Severe
Clitoris shrinking
Mild
Moderate
Severe
Clitorial pain
Mild
Moderate
Severe
Abnormal bleeding
Mild
Moderate
Severe
Painful episiotomy scar
Mild
Moderate
Severe
Changes in discharge (watery)
Mild
Moderate
Severe
Increased UTIs
Mild
Moderate
Severe
Stress urinary incontinence (e.g. peeing when you sneeze, exercise or cough)
Mild
Moderate
Severe
Urge incontinence (need to go NOW)
Mild
Moderate
Severe
Frequent urination
Mild
Moderate
Severe
Prolapse
Mild
Moderate
Severe
Painful smear test
Mild
Moderate
Severe
Are there any further details relating to the above symptoms would like to share?
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