Menopause Questionnaire

A comprehensive self-assessment tool to help understand your symptoms.

Takes about 8-12 minutes • All information is private

Step 1 of 4

Section 1: Personal & Medical Background

Age (years)

Weight (kg/lbs)

Height

Step 2 - Symptom Severity

Step 2 of 4

Select the severity level for each symptom: None, Mild, Moderate, Severe.

Hot flashes (daytime)

Night sweats

Chills or cold sweats

Heart palpitations or racing heart

Joint pain / stiffness

Muscle aches or weakness

Headaches / migraines

Dizziness or vertigo

Tingling or numbness in hands/feet

Dry or itchy skin, hair thinning, brittle nails

Difficulty falling asleep

Frequent night waking

Waking too early

Daytime fatigue

Feeling physically exhausted

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Step 3 - Frequency, Lifestyle & Triggers

Step 3 of 4

Symptom 1

Symptom 1

Frequency

Disruption Level