My Symptoms checklist

Menopause > My Symptoms checklist

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Section 1: Your Symptoms
Do You Have Periods?*
Do You Have Any Of The Following Symptoms?
1. Hot Flushes*
2. Night Sweats*
3. Difficulty Sleeping*
4. Mood Changes*
5. Low Energy*
6. Brain Fog*
7. Heart Palpitations*
8. Headaches &/or Migraines*
9. Loss Of Sex Drive*
10. Joint/Muscle Ache*
11. Vaginal Dryness*
12. Painful Intercourse*
13. Increased Urination Frequency*
Section 2: Medical History
Do You Have Any Of The Following Symptoms?
1. Have You Ever Been Diagnosed With Breast Cancer?*
2. Do You Have A Family History Of Breast Cancer?*
3. Have You Ever Been Told You’re At Risk Of/or Diagnosed With Venous Thromboembolism (Vte)?*
4. Have You Ever Suffered A Stroke?*
Section 3: You And Your Lifestyle
1. Which Age Group Do You Fit Into?*
2. Are Any Of The Above Symptoms Impacting Your Quality Of Life? E.g. Impact On Relationship With Partner, Home Life, Work Life*
3. Tell Us About Your Lifestyle:
1. Do You Smoke?*
2. Do You Drink Alcohol?*
3. Do You Exercise Regularly?*