Green Climactic Scale Self-Assessment
Please complete this self-assessment to help evaluate your climacteric symptoms. Your responses will be reviewed by a healthcare professional.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Over the past week, how much have you experienced the following symptoms? Please select the option that best describes your experience for each symptom.
Rate each symptom from 0 (Not at all) to 3 (Extremely).
Heart discomfort (unusual awareness of heartbeat, heart skipping, heart racing, tightness)
*
0 - Not at all
1 - A little
2 - Quite a bit
3 - Extremely
Irritability (feeling nervous or tense)
*
0 - Not at all
1 - A little
2 - Quite a bit
3 - Extremely
Sleep problems (difficulty in falling or staying asleep)
*
0 - Not at all
1 - A little
2 - Quite a bit
3 - Extremely
Memory Problems
*
0 - Not at all
1 - A little
2 - Quite a bit
3 - Extremely
Attacks of anxiety or panic
*
0 - Not at all
1 - A little
2 - Quite a bit
3 - Extremely
Difficulty concentrating
*
0 - Not at all
1 - A little
2 - Quite a bit
3 - Extremely
Feeling tired of lack of energy
*
0 - Not at all
1 - A little
2 - Quite a bit
3 - Extremely
Loss of interest in most things
*
0 - Not at all
1 - A little
2 - Quite a bit
3 - Extremely
Feeling unhappy or depressed
*
0 - Not at all
1 - A little
2 - Quite a bit
3 - Extremely
Crying spells
*
0 - Not at all
1 - A little
2 - Quite a bit
3 - Extremely
Irritability
*
0 - Not at all
1 - A little
2 - Quite a bit
3 - Extremely
Feeling dizzy or faint
*
0 - Not at all
1 - A little
2 - Quite a bit
3 - Extremely
Pressure or tightness in head
*
0 - Not at all
1 - A little
2 - Quite a bit
3 - Extremely
Tinnitus (ringing or buzzing in the ear)
*
0 - Not at all
1 - A little
2 - Quite a bit
3 - Extremely
Headaches
*
0 - Not at all
1 - A little
2 - Quite a bit
3 - Extremely
Muscle and/or joint pain
*
0 - Not at all
1 - A little
2 - Quite a bit
3 - Extremely
Pins and needles in any part of the body
*
0 - Not at all
1 - A little
2 - Quite a bit
3 - Extremely
Breathing difficulty
*
0 - Not at all
1 - A little
2 - Quite a bit
3 - Extremely
Hot flashes
*
0 - Not at all
1 - A little
2 - Quite a bit
3 - Extremely
Sweating at night
*
0 - Not at all
1 - A little
2 - Quite a bit
3 - Extremely
Loss of interest in sex
*
0 - Not at all
1 - A little
2 - Quite a bit
3 - Extremely
Urinary symptoms
*
0 - Not at all
1 - A little
2 - Quite a bit
3 - Extremely
Symptoms due to vaginal dryness
*
0 - Not at all
1 - A little
2 - Quite a bit
3 - Extremely
Total Green Climactic Scale Score
Submit Assessment
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