Menopause and Perimenopause Symptom Checklist
Please fill out the checklist to evaluate your symptoms.
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Vasomotor Symptoms
Symptom Severity
Rows
None
Low
Moderate
Severe
Hot Flashes
Night Sweats
Chills
Sleep Disturbance Symptoms
Symptom Severity
Rows
None
Low
Moderate
Severe
Insomnia
Restless Sleep
Early Awakening
Psychological Symptoms
Symptom Severity
Rows
None
Low
Moderate
Severe
Mood Swings
Anxiety
Depression
Irritability
Forgetfulness
Brain Fog
Panic Attacks
Feeling Overwhelmed Easily
Sexual and Genitourinary Symptoms
Symptom Severity
Rows
None
Low
Moderate
Severe
Vaginal Dryness
Decreased Libido
Painful Intercourse
Frequent Urination
Urinary Incontinence
Recurrent Urinary Tract Infections
Delayed Or Absent Arousal And Pleasure
Delayed Or Absent Orgasms
Physical Symptoms
Symptom Severity
Rows
None
Low
Moderate
Severe
Weight Gain
Increase in Belly Fat
Joint Pain
Fatigue
Muscle Pain
Hair Loss
Dry Skin
Brittle Nails
Headaches
Bloating
Digestive Upset
Ringing in Ears
Dizziness
Altered Taste Or Smell
Food Cravings: Especially Carbohydrates and Sweets
Change in Body Odor
Burning of the Tongue
Tingling Sensation in Extremities: Crawly Skin
Dry Eyes
Sensitivity To Temperature Changes
Loss of Motivation
Cardiovascular Symptoms
Symptom Severity
Rows
None
Low
Moderate
Severe
Palpitations
High Blood Pressure
Elevated Cholesterol Levels
Cognitive Symptoms
Symptom Severity
Rows
None
Low
Moderate
Severe
Reduced Memory Recall
Difficulty Concentrating
Emotional Symptoms
Symptom Severity
Rows
None
Low
Moderate
Severe
Tearfulness
Loss of Confidence
Skin and Hair Symptoms
Symptom Severity
Rows
None
Low
Moderate
Severe
Dry Skin
Thinning Hair
Facial Growth
Itchy Skin
Acne or Breakouts
Rosacea Flare-ups
Brittle Nails
Bone and Muscle Symptoms
Symptom Severity
Rows
None
Low
Moderate
Severe
Bone Density Loss
Muscle Weakness
Back Pain
Tendinitis
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