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Hot Flashes AbsentMildModerateSevere
Night Sweats AbsentMildModerateSevere
Insomnia AbsentMildModerateSevere
Fatigue AbsentMildModerateSevere
Forgetfulness AbsentMildModerateSevere
Vaginal Dryness AbsentMildModerateSevere
Low Libido AbsentMildModerateSevere
Inability to Climax AbsentMildModerateSevere
Weight gain AbsentMildModerateSevere
Dry Skin AbsentMildModerateSevere
Hair Loss AbsentMildModerateSevere
Constipation AbsentMildModerateSevere
Brittle Nails AbsentMildModerateSevere
Cold Extremities AbsentMildModerateSevere
Lack of focus AbsentMildModerateSevere
Heat Palpitations AbsentMildModerateSevere
Hand Tremors AbsentMildModerateSevere
Anxiety AbsentMildModerateSevere
Depression AbsentMildModerateSevere
Heavy Menstrual Cycles AbsentMildModerateSevere
Irregular Menstrual Cycles AbsentMildModerateSevere
Irritability AbsentMildModerateSevere
Fluid retention AbsentMildModerateSevere
Acne AbsentMildModerateSevere
Breast Tenderness AbsentMildModerateSevere
Headaches AbsentMildModerateSevere
Do you leak urine when you cough, sneeze, laugh, exercise? NAMildModerateSevere
Are you fasting today? NANoYes
Have you taken your thyroid medication today? NANoYes
Are you on an estrogen patch? NANoYes [group estrogen clear_on_hide] If on an estrogen patch what date did you last changed your patch? Any missed doses in the last week: NoYes [/group]
Patient Signature:
Date
PMSPeri-MenopauseMenopause
Pelvic Floor HealthUrinary Incontinence
Hypothyroid & Hashimoto’s Thyroiditis
Anti-AgingAge Management
Women’s Health
PCOS-Polycystic Ovarian Syndrome
Sexual Intimacy
AndopauseMale Menopause
