Symptom Check-in — The Menopause Clinic

Symptom Check-in — The Menopause Clinic

This tracker is not monitored in real time. If you have urgent or emergency symptoms, please seek care right away through urgent care, the ER, or your primary care provider. This check-in helps us track symptoms over time while your treatment is adjusting. You do not need to remember past symptoms — just answer how things feel today. We review patterns, not single days.
Full name*
Date of birth*

MonthDayYear
Date
Date you started or most recently changed your estrogen dose*

MonthDayYear
Date
BetterSameWorseJust starting / first check-in
Hot flashes / Night sweats*

1

2

3

4

5

1 is Worst, 5 is Best
Trouble falling asleep*

1

2

3

4

5

1 is Worst, 5 is Best
Trouble staying asleep*

1

2

3

4

5

1 is Worst, 5 is Best
Brain fog / Trouble focusing / Finding words*

1

2

3

4

5

1 is Worst, 5 is Best
Mood swings / Irritability*

1

2

3

4

5

1 is Worst, 5 is Best
Low energy / Fatigue*

1

2

3

4

5

1 is Worst, 5 is Best
Joint pain*

1

2

3

4

5

1 is Worst, 5 is Best
Vaginal dryness or pain with sex*

1

2

3

4

5

1 is Worst, 5 is Best
Urinary symptoms (leaking, urgency, burning, UTIs)*

1

2

3

4

5

1 is Worst, 5 is Best
Breast tenderness*

1

2

3

4

5

1 is Worst, 5 is Best
Bloating*

1

2

3

4

5

1 is Worst, 5 is Best
No issues — sticking wellMild skin irritationPatch not sticking flat (wrinkling or lifting)Patch crinkling or bunchingNot applicable — I don't use a patch
YesNo
Light spottingLight-mild bleedingHeavy bleeding
Are there any new side effects or changes you've noticed? Anything you'd like your provider to know?
Should be Empty: