Menopause Rating Scale (MRS)
Before HRT
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Birthday
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Rate each symptom you are Experiencing. For symptoms that do not apply mark none
*
Rows
None
Mild
Moderate
Severe
Extremely Severe
Hot flashes, sweating (episodes of sweating)
Heart discomfort (unusual awareness of heart beat, heart skipping, heart racing, tightness)
Sleep problems (difficulty in falling asleep, difficulty insleeping through the night, waking up early)
Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings)
Irritability (feeling nervous, inner tension, feeling aggressive)
Anxiety (inner restlessness, feeling panicky)
Physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness)
Sexual problems (change in sexual desire, in sexual activity and satisfaction
Bladder problems (difficulty in urinating, increased need to urinate, bladder incontinence)
Dryness of vagina (sensation of dryness or burning in the vagina, difficulty with sexual intercourse) Type a question
Joint and muscular discomfort (pain in the joints, rheumatoid complaints)
MRS Score
Severity
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 the criteria. This is physical activity that accelerates your heartrate/breathlessness
*
0-1 day per week (Low)
2-3 days per week (Average)
More than 3 days a week (High)
Please list any prior hormone therapy
Submit
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