Questionnaire about Menopause Symptoms

Your Name:
Your Email Address:
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Age:
Race:	White Black Asian American Indian Pacific Islander Other
Weight:	(pounds)

What was the date of your last period?

When did you start to notice that your periods had changed?

Usually, how many days were there between your periods?

Less than 25 days   25 to 32 days   33 to 42 days   More than 42 days  

For how many days did your periods usually last?

3 to 6 days   7 to 10 days   More than 10 days  

How would you have described your menstrual flow?

Light   Moderate   Heavy  

Did you experience blood clots in your menstrual flow, and if so how large were they?

None   Small   Medium   Large   

Did you experience abdominal cramp during your menstrual period?

None   Mild   Moderate   Severe   

Which of the following menopause symptoms are you are experiencing?

Irregular vaginal bleeding	Hot flashes and night sweats	Vaginal dryness	Trouble sleeping
Mood swing	Depression	Anxiety	Fatigue
Headache	Thinning hair	Loss of libido(sex drive)	Weight gain
Troubles with concentration

Others symptoms (please specify):

Do you have any disorder of the pelvic area that might be related to your menopausal symptoms ?

Yes,  (please specify):
No

Are you under any medication?

Yes   (please specfy):
No  

How did you hear about us?

Internet Friends Health Practioner Other
If "Other", please specify: (Google, WebMD, etc..)

If you have any further comments or questions, please write these in the box below :

Attachment:

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