I have hot flashes                                       No Yes How often?

I have night sweats                                    No Yes How often?

I have mood swings                                   No Yes How often?

I feel irritable                                              No Yes How often?

I feel depressed                                         No Yes How often?

I have difficulty getting to sleep                 No Yes How often?

I have difficulty staying asleep?                 No Yes How often?

I have heart palpitations                             No Yes How often?

I feel more tired than usual                         No Yes How often?

My vagina is dry or itchy                             No Yes How often?

I have pain during intercourse                     No Yes How often?

I lack desire or interest in sexual activity     No Yes How often?