Fit & Well Fed
Could it be perimenopause?
Name
First Name
First and last letter of last name
Date of birth
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Over the last 6 months, how often have you been bothered by the following symptoms?
Rows
Not at all
Several Days
More than half the days
Nearly every day
1. Hot Flashes and/or night sweats
2. Feeling unhappy, anxious, depressed or hopeless
3. Trouble staying asleep, or waking through the night
4. Feeling tired or having little energy
5. Loss of muscle mass
6. Joint pain
7. Low Libido
8. Painful intercourse
9. Heart palpitations
10. Headaches or increase in headaches
11. Dry eyes and/or mouth
12. New onset of body odor or bad breath
13. Pain in the feet or plantar fasciitis
14. Bladder leaking, urgency, UTI's
15. Swelling of hands or feet
16. Nipple or breast sensitivity/pain
17. Brain fog or trouble concentrating
18. Abdominal weight gain
19. Increase in cellulite
20. Changes in hair/skin
21. Gas and/or bloating
22. Heartburn or indigestion
23. Menstrual changes or irregularities
24. Frozen Shoulder
25. Itchy ears
26. Crawling feeling under skin
Perimenopause Symptom Score (0-4 Moderate) (5-10 Moderately Severe) (11-26 Severe)
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