Before HRT Checklist (Female)
Place an "X" for EACH symptom you are currently experiencing. Please mark only ONE box. For symptoms that do not apply, please mark NONE.
Rows
Choose One
1. Hot flashes, sweating (episodes of sweating)
1 (None)
2 (Mild)
3 (Moderate)
4 (Severe)
5 (Extremely Severe)
2. Heart discomfort (unusual awareness of heartbeat, 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 day per week (Low)
2·3 days per week (Average)
More than 3 days per week (High)
Please list any prior hormonal therapy?
Submit
Should be Empty: