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Do you suffer from night sweats or hot flashes?
Yes
No
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Do you notice yourself feeling more stressed, anxious, or nervous lately?
Never
Sometimes
Often
Always
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Have you gained weight especially in your abdomen, hips, buttocks, and thighs or have difficulty losing the weight?
Yes
No
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Do you have trouble sleeping?
Never
Sometimes
Often
Always
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Do you find yourself having difficulty concentrating or focusing?
Never
Sometimes
Often
Always
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Do you have less interest in sex?
Yes
No
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Do you feel irritated, inpatient, have outbursts of anger, or feel out of control with your emotions?
Never
Sometimes
Often
Always
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What is your current age range?
Less than 35
35-40
41-45
46-50
51-56
56+
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