ADAM Questionnaire

1

Personal Information

First Name

Last Name

Date of Birth

2

Menopause Ratings Scale Results

Psychological (0 to 16)

Somato-Vegetative (0 to 16)

Urogenital (0 to 12)

Total (0 to 44)

3

Do you have a decrease in libido (sex drive)?

YESNO

4

Do you have a lack of energy?

YESNO

5

Have you lost height?

YESNO

6

Have you noticed a decrease in "enjoyment of life?"

YESNO

7

Are you sad and/or grumpy?

YESNO

8

Are your erections less strong?

YESNO

9

Have you noticed a recent deterioration in your ability to play sports?

YESNO

10

Are you falling asleep after dinner?

YESNO

11

Has there been a recent deterioration in your work performance?

YESNO