Menopause Symptoms Questionnaire

This can be used to monitor symptoms and is worth doing regularly to assess how symptoms change with time or with treatment.

Please print this page and indicate the extent to which you are bothered at the moment by any of these symptoms by placing a tick in the appropriate box:

SymptomsNot at all 0A little 1Quite a bit 2Extremely 3Comment
Heart beating quickly or strongly     
Feeling tense or nervous     
Difficulty in sleeping     
Memory Problems     
Attacks of anxiety, panic     
Difficulty in concentrating     
Feeling tired or lacking in energy     
Loss of interest in most things     
Feeling unhappy or depressed     
Crying spells     
Feeling dizzy or faint     
Pressure or tightness in head     
Tinnitus (ringing or buzzing in ear)     
Muscle or joint pains     
Pins and needles in any part of the body     
Breathing difficulties     
Hot flushes     
Sweating at night     
Loss of interest in sex     
Urinary Symptoms     
Symptoms due to vaginal dryness     
Periods – Are you bleeding?     

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