Hormone Replacement Therapy Symptom Checklist for WomenPlease complete the form below, and we’ll be in touch shortly! We can't wait to hear from you! Name * First Name Last Name Date of Birth * MM DD YYYY Email * Phone (###) ### #### 1. Hot flashes, sweating * Episodes of sweating None Mild Moderate Severe Extremely Severe 2. Heart discomfort * Unusual awareness of heart beat, heart skipping, heart racing, tightness None Mild Moderate Severe Extremely Severe 3. Sleep problems * Difficulty in falling asleep, difficulty in sleeping through the night, waking up early None Mild Moderate Severe Extremely Severe 4. Depressive mood * Feeling down, sad, on the verge of tears, lack of drive, mood swings None Mild Moderate Severe Extremely Severe 5. Irritability * Feeling nervous, inner tension, feeling aggressive None Mild Moderate Severe Extremely Severe 6. Anxiety * Inner restlessness, feeling panicky None Mild Moderate Severe Extremely Severe 7. Physical and mental exhaustion * General decrease in performance, impaired memory, decrease in concentration, forgetfulness None Mild Moderate Severe Extremely Severe 8. Sexual problems * Change in sexual desire, in sexual activity, and satisfaction None Mild Moderate Severe Extremely Severe 9. Bladder problems * Difficulty in urinating, increased need to urinate, bladder incontinence None Mild Moderate Severe Extremely Severe 10. Dryness of vagina * Sensation of dryness or burning in the vagina, difficulty with sexual intercourse None Mild Moderate Severe Extremely Severe 11. Joint and muscular discomfort * Pain in the joints, rheumatoid complaints None Mild Moderate Severe Extremely Severe Please share any additional comments about your symptoms you would like to address. * If you don't have additional comments to share, please write "None." Do you have cold hands and feet? * Yes No Do you have daily bowel movements? * Yes No Do you have gas, bloating, or abdominal pain after eating? * Yes No Please select your WEEKLY activity level based on this criteria: * Physical activity that accelerates heart rate / breathlessness 0-1 day per week (low) 2-3 days per week (average) More than 3 days per week (high) Please list any prior hormone therapy * If you've never had hormone therapy, please write "None." Thank you! I’ll be in touch with you shortly.