Past Medical History- Female HRT

If yes, please skip 7-16.

Rate each of the following symptoms based upon your typical health profile for the past 30 days:

Point Scale

0 - Never or almost never have the symptom
1 - Occasionally have it, effect is not severe
2 - Occasionally have it, effect is severe
3 - Frequently have it, effect is not severe
4 - Frequently have it, effect is severe

Rows	0	1	2	3	4
Headaches
Faintness
Dizziness
Insomnia

Rows	0	1	2	3	4
Watery or itchy eyes
Swollen, reddened or sticky eyelids
Bags or drack circles under eyes
Blurred or tunnel vision (does not include near or far-sightedness)

Rows	0	1	2	3	4
Itchy Ears
Earaches, Ear infections
Drainage from ear
Ringing in ears, hearing loss

Rows	0	1	2	3	4
Stuffy nose
Sinus problems
Hay fever
Sneezing
Sneezing attacks
Excessive mucus formation

Rows	0	1	2	3	4
Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Swollen or discolored tongue, gyms. Lips
Canker sores

Rows	0	1	2	3	4
Acne
Hives, rashes, dry skin
Hair loss
Flushing, hot flashes
Excessive sweating

Rows	0	1	2	3	4
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest pain

Rows	0	1	2	3	4
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing

Rows	0	1	2	3	4
Nausea, vomiting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intestinal/stomach pain

Rows	0	1	2	3	4
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Pain or aches in muscles
Feeling of weakness or tiredness

Rows	0	1	2	3	4
Binge eating/drinking
Craving certain foods
Excessive weight
Compulsive eating
Water retention
Underweight

Rows	0	1	2	3	4
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness

Rows	0	1	2	3	4
Poor memory
Confusion, poor comprehension
Poor concentration
Poor physical coordination
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities

Rows	0	1	2	3	4
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression

Rows	0	1	2	3	4
Frequent illness
Frequent or urgent urination
Genital itch or discharge

In the past 2 weeks, please indicate if you have had any of these symptoms, and rate the symptom from 1 to 5. 1 - not too much of a problem - 5 - very much a problem. Use the comment area below to explain further if needed.

Rows	1	2	3	4	5	N/A
Anxiety/irritability
Tearful
Sleep disturbance/insomnia
Mood Swings
Breakthrough Bleeding
Decreased concentration
Brain fog or Memory loss
Feeling overwhelmed
Night sweats/hot flashes
Fatigue
Vaginal dryness
Breast tenderness
Heavy Periods
Depression Symptoms
Urinary Incontinence
Swelling in hands/feet
Hot flashes during the day
Muscle gain/loss
Lack of Motivation
Acne or Oily Skin
Low Libido
Poor recovery after workouts
Craving Sweets or Salt
Constipation or Diarrhea
Hot/cold feet or hands
Difficulty losing weight
Hair Loss/thinning hair
Pain during sex

Complaints and Concerns

Medical Symptoms Questionnaire (MSQ)