Health Assessment For Women

Health Assessment For Women

Female Symptom Questionnaire
Name

First NameLast Name
Email
example@example.com
Date

MonthDayYear
Date
Which of the following symptoms apply to you currently (in the past 2 weeks)?

For that do not currently apply or no longer apply, mark "never".

SYMPTOMS

	Never (0)	Mild (1)	Moderate (2)	Severe (3)	Very Severe (4)
Hot flashes
Sweating (night sweats or increased episodes of sweating)
Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early)
Depressive mood (feeling down, sad, on the verge of tears, lack of drive)
Irritability (mood swings, feeling aggressive, angers easily)
Anxiety (inner restlessness, feeling panicky, feeling nervous, inner tension)
Physical exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation)
Sexual problems (change in sexual desire, in sexual activity and/or orgasm and satisfaction)
Bladder problems (difficulty in urinating, increased need to urinate, incontinence)
Vaginal symptoms (sensation of dryness or burning in vagina, difficulty with sexual intercourse
Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after excercise)
Difficulties with memory
Problems with thinking, concentrating or reasoning
Difficulty learning new things
Trouble thinking of the right word to describe persons, places or things when speaking
Increase in frequency or intensity of headaches or migraines
Hair loss, thinning or change in texture of hair
Feel cold all the time or have cold hands or feet
Weight gain or difficulty losing weight despite diet and exercise
Dry or wrinkled skin

Which of the following symptoms apply to you currently (in the past 2 weeks)?