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HRT Female MRS Checklist
Mark EACH symptom you are currently experiencing. Please mark only ONE box. For symptoms that do not apply, please mark NONE.
Nota: Este formulario también está disponible en español. Seleccione su preferencia de idioma en el menú desplegable ubicado en la parte superior derecha de este formulario para cambiar a la versión en español.
1. Hot flashes, sweating (episodes of sweating)
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremely Severe
2. Heart discomfort (unusual awareness of heart beat, heart skipping, heart racing, tightness)
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremely Severe
3. Sleep problems (difficulty in falling asleep, difficulty in sleeping through the night, waking up early)
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremely Severe
4. Depressive mood (feeling down, sad, on the verge of tears,lack of drive, mood swings)
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremely Severe
5. Irritability (feeling nervous, inner tension, feeling aggressive)
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremely Severe
6. Anxiety (inner restlessness, feeling panicky)
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremely Severe
7. Physical and mental exhaustion (general decrease in performance,impaired memory, decrease in concentration, forgetfulness)
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremely Severe
8. Sexual problems (change in sexual desire,in sexual activity and satisfaction)
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremely Severe
9. Bladder problems (difficulty in urinating, increased need to urinate, bladder incontinence)
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremely Severe
10. Dryness of vagina (sensation of dryness or burning in the vagina,difficulty with sexual intercourse)
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremely Severe
11. Joint and muscular discomfort (pain in the joints, rheumatoid complaints)
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremely Severe
Please share any additional comments about your symptoms you would like to address.
Do you have cold hands and feet?
*
Yes
No
Do you have daily bowel movements?
*
Yes
No
Do you have gas, bloating or abdominal pain after eating?
*
Yes
No
Please select your WEEKLY Activity Level based on this criteria -> Physical Activity that accelerates heart rate/Breathlessness
*
0-1 per day (Low)
2-3 per week (Average)
More than 3 days per week (High)
Please list any prior hormone therapy? (Write none if not applicable)
*
Most recent weight
*
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: