Resources | 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:

Symptoms Not at all 0 A little 1 Quite a bit 2 Extremely 3 Comment
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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