Your Midlife Health & Symptom Tracker (Perimenopause & Menopause)

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

✨ Intro

Every woman’s midlife transition is unique. Whether you’re experiencing perimenopause (the years leading up to menopause) or menopause itself, this quiz helps you notice patterns in your symptoms. By tracking frequency and intensity, you can see trends that show where your body and mind may need extra support.

📝 Instructions

As you go through this quiz, please take a moment to review each symptom and rate how often it shows up for you on a scale of 0–4 (0 = Never, 4 = Daily occurrence). If you’re using your phone, don’t forget to scroll all the way to the right to see all the answer options.

😔 Mood, Mind & Sleep

	Never-0	Rarely-1	Sometimes-2	Often-3	Severe/Daily- 4
My emotions feel unpredictable (mood swings).
I feel anxious, tense, or restless.
I feel down, sad, or uninterested in things I usually enjoy.
I feel irritable or more easily frustrated.
I often feel tired, even after sleeping.
I struggle to fall asleep or stay asleep.
I forget names or lose track of tasks more often.
I have trouble focusing or concentrating.

🔥Vasomotor (Heat-Related)

	Never-0	Rarely-1	Sometimes-2	Often-3	Severe/Daily- 4
I have sudden hot flashes (rushes of heat).
I wake up sweaty at night.
I feel electric shock or “zapping” sensations.
I sometimes feel cold chills or overly sensitive to cold.

💓 Heart, Circulation & Nerves

	Never-0	Rarely-1	Sometimes-2	Often-3	Severe/Daily- 4
My heart races, pounds, or skips beats.
I feel lightheaded or dizzy.
I get headaches or migraines.
I notice tingling, “pins and needles,” in my hands or feet.
I hear ringing in my ears (tinnitus).
My muscles feel tight or tense.
I notice changes in my cholesterol or blood pressure.

🦴 Bones, Joints & Muscles

	Never-0	Rarely-1	Sometimes-2	Often-3	Severe/Daily- 4
My joints feel achy, stiff, or sore.
My muscles feel weak, sore, or easily fatigued.
I worry about bone loss (osteoporosis risk).
I feel like it takes me longer to recover from exercise or illness.

🩸Reproductive, Bladder & Sexual Health

	Never-0	Rarely-1	Sometimes-2	Often-3	Severe/Daily- 4
My periods are irregular or have stopped.
I notice vaginal dryness or discomfort.
Intimacy is painful or uncomfortable.
My sexual desire has changed (higher or lower).
I feel less connected to my partner due to these changes.
My breasts feel different (tender, less full, or less firm).
I leak urine when I cough, sneeze, or exercise.
I struggle to fully empty my bladder.
I have pain, burning, or urgency with urination.
I get urinary tract infections more often

🧍‍♀️ Skin, Hair, & Body Changes

	Never-0	Rarely-1	Sometimes-2	Often-3	Severe/Daily- 4
My hair feels thinner or I notice hair loss.
I notice new facial hair (like chin hairs).
My skin feels dry or itchy.
My nails are brittle.
I’ve gained weight or notice changes in body shape.
My body odor has changed.
My breasts have lost some fullness.

👁️ Eyes, Mouth & Digestion

	Never-0	Rarely-1	Sometimes-2	Often-3	Severe/Daily- 4
My eyes feel dry or my vision has changed.
My gums are sore, red, or bleed more easily.
My mouth feels dry or food tastes different.
I feel bloated, constipated, or notice other digestive changes.

🌾 Immune & Sensitivities

	Never-0	Rarely-1	Sometimes-2	Often-3	Severe/Daily- 4
I have new or worsening allergies.
I seem to catch colds or viruses more easily.

💭 Body Image & Confidence

	Never-0	Rarely-1	Sometimes-2	Often-3	Severe/Daily- 4
I feel less comfortable in my own skin.
I struggle to accept physical changes.
I feel less confident socially, sexually, or personally.
I sometimes feel my self-worth is lower than before.

After completing this survey, is there any other concern that you might have that would help Kelly help support you?

Thank you for taking the time to complete this quiz. Kelly will reach out soon to share your results and talk together about possible next steps for your care and comfort. 💙