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*

Sweating (night sweats or increased episodes of sweating)*

Sleep Problems (difficulty falling asleep, sleeping through the night or waking up too early)*

Depressive Mood (feeling down, sad, on the verge of tears, lack of drive)*

Irritability (Mood swings, feeling aggressive, angers easily)*

Anxiety (inner restlessness, feeling panicky, feeling nervus, inner tension)*

Physical Exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation)*

Sexual Problems (change in sexual desire, sexual activity, orgasm and or satisfaction)*

Bladder Problems (difficulty in urinating, increased need to urinate, incontinence)*

Vaginal Symptoms (sensation of dryness or burning in the vagina, difficulty with sexual intercourse)*

Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)*

Difficulties with Memory*

Problems with thinking, concentrating or reasoning*

Difficulty Learning New Things*

Trouble thinking of the right word to describe persons, places or things when speaking*

Increase in frequency or intensity of headache or migraines*

Hair loss, thinning or changed in texture of hair*

Feeling cold all the time or have cold hands or feet*

Weight gain or difficulty losing weight despite diet and exercise*

Dry or Wrinkly Skin*

Any other symptoms or concerns