Female Assessment Form

Name

Email

Today's Date

Phone

Are you experiencing any symptoms? If yes, please mark the appropriate box for each symptom you may be experiencing. Yes No

Physical Exhaustion (fatigue, lack of energy, stamina or motivation) None Mild
Moderate Severe
Very Severe

Sleep Problems (difficulty falling asleep or sleeping through the night) None Mild
Moderate Severe
Very Severe

Irritability (mood swings, feeling aggressive, angers easily) None Mild
Moderate Severe
Very Severe

Anxiety (feeling overwhelmed, feeling panicky, or feeling nervous) None Mild
Moderate Severe
Very Severe

Decline in drive or interest (loss of “zest for life,” feeling down or sad) None Mild
Moderate Severe
Very Severe

Joint and muscular symptoms (joint pain, muscle weakness, poor recovery after exercise) None Mild
Moderate Severe
Very Severe

Difficulties with memory (concentration, finding the right word, or retaining information) None Mild
Moderate Severe
Very Severe

Vaginal dryness or difficulty with sexual intercourse None Mild
Moderate Severe
Very Severe

Sexual Problems (change in desire, activity, orgasm and/or satisfaction) None Mild
Moderate Severe
Very Severe

Sweating (night sweats or increased episodes of sweating) None Mild
Moderate Severe
Very Severe

Hot Flashes (burst that starts in chest and lasts for short duration) None Mild
Moderate Severe
Very Severe

Hair loss, thinning or change in texture of hair None Mild
Moderate Severe
Very Severe

Feeling cold all the time, having cold hands or feet None Mild
Moderate Severe
Very Severe

Headaches or migraines (increase in frequency or intensity) None Mild
Moderate Severe
Very Severe

Weight (difficulty losing weight despite diet/exercise) None Mild
Moderate Severe
Very Severe

Bladder problems (difficulty in urinating, increased need to urinate, incontinence) None Mild
Moderate Severe
Very Severe

Other symptoms or unique health circumstances to take into consideration:

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