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Questions Yes / No

Do you suffer from hot flashes?

Yes No

Do you have night sweats?p>

Yes No

Do you have a lack of energy?

Yes No

Do you notice yourself feeling more stressed, anxious or nervous?

Yes No

Have you gained weight, especially in your abdomen, hips, buttocks or thighs?

Yes No

Do you have trouble sleeping?

Yes No

Is it harder to remember things?

Yes No

Do you feel depressed?

Yes No

Have you lost interest in sex?

Yes No

Have you experienced vaginal dryness?

Yes No

Do you feel irritable, impatient or angry, without control over your emotions?

Yes No

Do you have urinary leakage when you cough or sneeze?

Yes No
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