Female HRT Symptom Questionnaire

Full Name*

First NameLast Name
DOB*

MonthDayYear
Date
Date*

MonthDayYear
Date
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. Please use the comment area below to explain further or comment.

Rows	1	2	3	4	5	N/A
Anxiety/irritablity
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