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Female Health Assessment Form
Which of the following symptoms have you been experiencing in the last two weeks?
Please mark the appropriate box for each symptom. For symptoms that do not currently apply or no longer apply Mark None.
Hot Flashes*
None
Mild
Moderate
Severe
Very Severe
Sweating (night sweats or increased episodes of sweating)*
None
Mild
Moderate
Severe
Very Severe
Sleep Problems (difficulty falling asleep, sleeping through the night or waking up too early)*
None
Mild
Moderate
Severe
Very Severe
Depressive Mood (feeling down, sad, on the verge of tears, lack of drive)*
None
Mild
Moderate
Severe
Very Severe
Irritability (Mood swings, feeling aggressive, angers easily)*
None
Mild
Moderate
Severe
Very Severe
Anxiety (inner restlessness, feeling panicky, feeling nervus, inner tension)*
None
Mild
Moderate
Severe
Very Severe
Physical Exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation)*
None
Mild
Moderate
Severe
Very Severe
Sexual Problems (change in sexual desire, sexual activity, orgasm and or satisfaction)*
None
Mild
Moderate
Severe
Very Severe
Bladder Problems (difficulty in urinating, increased need to urinate, incontinence)*
None
Mild
Moderate
Severe
Very Severe
Vaginal Symptoms (sensation of dryness or burning in the vagina, difficulty with sexual intercourse)*
None
Mild
Moderate
Severe
Very Severe
Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)*
None
Mild
Moderate
Severe
Very Severe
Difficulties with Memory*
None
Mild
Moderate
Severe
Very Severe
Problems with thinking, concentrating or reasoning*
None
Mild
Moderate
Severe
Very Severe
Difficulty Learning New Things*
None
Mild
Moderate
Severe
Very Severe
Trouble thinking of the right word to describe persons, places or things when speaking*
None
Mild
Moderate
Severe
Very Severe
Increase in frequency or intensity of headache or migraines*
None
Mild
Moderate
Severe
Very Severe
Hair loss, thinning or changed in texture of hair*
None
Mild
Moderate
Severe
Very Severe
Feeling cold all the time or have cold hands or feet*
None
Mild
Moderate
Severe
Very Severe
Weight gain or difficulty losing weight despite diet and exercise*
None
Mild
Moderate
Severe
Very Severe
Dry or Wrinkly Skin*
None
Mild
Moderate
Severe
Very Severe
Any other symptoms or concerns
Submit
×
Mia Hartman
USA
8022724631
•
nphartman.22@gmail.com
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