Hormone Health Tracker
MAKE MIDLIFE YOUR SUPERPOWER
You may have heard about hot flashes and mood swings, but did you know there are now over 48 known symptoms associated with menopause? If you’re over 38, struggling with persistent issues or simply no longer ‘feel like you’, it may be a sign that your hormones need attention. This symptom benchmarking question set is based on the same evaluation criteria used by many practitioners, using the MENQOL and Greene Climacteric Scale to understand the severity of your symptoms. Simply complete, return - and we'll get back with a tailored recommendation just for you.
Name
*
First Name
Last Name
Age
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Using a scale of 0-6 where 0 is 'not at all bothered' and 6 is 'extremely bothered', please pick a score for each symptom.
1. Hot flashes
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
2. Night sweats
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
3. Sweating
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
4. Dissatisfaction with my personal life
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
5. Feeling anxious or nervous
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
6. Poor memory
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
7. Accomplishing less than I used to
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
8. Feeling depressed, down or blue
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
9. Being impatient with other people
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
10. Feelings of wanting to be alone
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
11. Flatulence (wind) or gas pains
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
12. Aching in muscles and joints
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
13. Difficulty sleeping
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
14. Feeling tired or worn out
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
15. Aches in back of head or neck
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
16. Decrease in physical strength
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
17. Decrease in stamina
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
18. Lack of energy
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
19. Dry skin
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
20. Weight gain
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
21. Increased facial hair
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
22. Changes in the appearance, texture or tone of my skin
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
23. Feeling bloated
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
24. Low backache
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
25. Frequent urination
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
26. Involuntary urination when laughing or coughing
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
27. Decrease in my sexual desire
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
28. Vaginal dryness
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
29. Avoiding intimacy
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
30. Breast pain or tenderness
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
31. Vaginal bleeding or spotting
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
32. Leg pains or cramps
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
33. Bloating/abdominal distension
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
34. Wind/flatulence
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
35. Feeling of fullness and discomfort after eating a meal
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
36. Constipation/difficulty in passing a stool
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
37. Diarrhea
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
38. Food cravings
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
39. Loose stools
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
40. Hard stools
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
41. Feeling of not emptying your bowels completely
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
42. Urgency in passing a stool
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
43. Heartburn or reflux
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
44. Stomach pain or cramping
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
45. Burping
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
46. Fatigue
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
47. Irritability
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
48. Brain fog
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
49. Nausea
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
50. Difficulty in engaging in social activities (e.g. eating out with friends, doing exercise) due to digestive discomfort or fear that activity may trigger digestive symptoms
*
Not at all bothered
0
1
2
3
4
5
Extremely bothered
6
0 is Not at all bothered, 6 is Extremely bothered
Submit
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