Menopause by hedongchenchen

VIEWS: 4 PAGES: 50

									MAJOR CATEGORY MINOR CATEGORY   Specific category

Condition     General History




Condition     Risk Factors      Current medical status




Condition     Risk Factors      Genetics




                                                         Have you had a pulmonary embolism?
                                                         Do you have varicose veins?
                                                         Do you have problems with bleeding easily from cuts?
                                                         Have you been told you have glaucoma?
                                          Did you have this condition before the onset of menop
                                          Do or did any of your blood relatives have glaucoma?
                                          Have you been told you have osteoporosis?
                                          Has your height decreased from your tallest remembe
                                          How much has it decreased?
                                          Have you had a fractured hip?
                                          Have you had a fracture in your spine?
                                          Have you had a bone density study?
                                          What did the results indicate? (Choose from selections
                                          Have you been told that you have diabetes?
                                          Did you have this condition before the onset of menop
                                          Do or did any of your blood relatives have this conditio
                                          If you have diabetes do you control it by diet?
                                          Do you control it by oral medication?
                                          Do you control it by insulin?
                                          Have you been told you have breast cancer?
                                          Did you have this condition before the onset of menop
                                          Do or did any of your female blood relatives have this c
                                          Do or did they have breast cancer before the age of 50
                                          Did any of them die due to breast cancer?
                                          Do or did any of your male relatives have breast cance
                                          Did any of them die due to breast cancer?
                                          Have you been told you have ovarian cancer?
                                          Did you have this condition before the onset of menop
                                          Do or did any of your female blood relatives have this c
                                          Do or did they have ovarian cancer before the age of 5
                                          Did any of them die due to ovarian cancer?
                                          Have you been told you have colorectal cancer?




Condition   Medical History   Menstrual




                                          Has the number of days between your period increase
                                          Has the number of days between your period decrease
                                          Has there been a recent change in the length of your p
                                          How many days do your periods last?
                                          Has the number of days of your period increased over
                                          Has the number of days of your period decreased ove
                                          Are your periods longer than 8 days?
                                          Is your period heavier than it was in the past? (Scale)
                                                 If yes, how much heavier is your period? (Scale)
                                                 Is your period lighter than it was in the past? (scale)
                                                 If yes, how much lighter than it was in the past?
                                                 Do you feel you have a problem with your period?
                                                 Have you discussed your concerns about your period w
                                                 Do you have problems with PMS (bloating, mood swin
                                                 Do you have spotting or bleeding in between periods?
                                                 How often does this happen?




Condition       Medical History   Reproductive




Physiological   Vasomotor         Symptoms




                                                 Do the hot flashes come in groups or waves?
                                                 How many times a day do you experience hot flashes?
                                                 Is there a time of day when you have more hot flashes
                                                 What time of day do you have more hot flashes?
                                                 Is there a time of day when you have fewer hot flashes
                                                 What times of day do you have the fewest hot flashes?
                                                 Do you have hot flashes at night?
                                                 Do you wake up due to hot flashes?
                                                 If you sleep with someone, do your hot flashes cause t
                                                 Do your night sweats/hot flashes cause your bed linen
                                                 Do your night sweats/hot flashes cause your bed linen
                                                 Have your hot flashes impacted on the quality of your s
                                                 Have your hot flashes impacted on the duration of you
                                                 Does your heart beat faster during a hot flash?
                                                 How long have you been experiencing hot flashes?
                                                 When did you first experience your first hot flash?
                                                 Did you know what was happening when you experien
                                                 What emotion did you feel when you experienced your
                                                 Do you feel anxious when you have a hot flash?
                                                 Do you feel uncomfortable when you have a hot flash?
                                                 Do you feel annoyed when you have a hot flash?
                                                 Do you feel embarrassed when you have a hot flash?
                                                 Do you feel angry when you have a hot flash?
                                                 Do you feel depressed when you have a hot flash?
                                                 Do you feel debilitated when you have a hot flash?
                                                 Have your hot flashes increased in intensity since your
                                                 Have your hot flashes increased in duration since your
                                                 Have your hot flashes increased in frequency since yo
                                                 Have your hot flashes decreased in intensity since you
                                                 Have your hot flashes decreased in duration since you
                                                 Have your hot flashes decreased in frequency since yo
                                                 Have your hot flashes remained the same?
                                                 Has your attitude changed about your hot flashes?
                                                 Have you become more accepting of the hot flashes?
                                                 Have you become less accepting of the hot flashes?
                                                 Has your quality of life suffered due to your hot flashes
                                                 Does being in a confined space cause you to have a h
                                                 Do you experience more hot flashes when in a confine
                                                 Does being in the heat cause you to have a hot flash?
                                                 Do you experience more hot flashes when it is hot?
                                                 Does being in humidity cause you to have a hot flash?
                                                 Do you experience more hot flashes when it is humid?
                                                 Does eating spicy food cause you to have a hot flash?
                                                 Do you experience more hot flashes after eating spicy
                                                 Are there other types of foods that cause you to have h
                                                 If yes, select the food groups that cause you to have h
                                                 Does drinking caffeinated beverages cause you to hav
                                                 Do you experience more hot flashes after drinking caff




Physiological   Vasomotor symptoms   Treatment
Physiological   Vasomotor symptoms   Alternative therapies



                                                             Would you like information on herbal therapies for relie
                                                             Have you tried Vitamin C with bioflavanoids to relieve h
                                                             Has Vitamin C with bioflavanoids been effective in relie
                                                             Have you tried dong quai to relieve hot flashes?
                                                             Has dong quai been effective in relieving hot flashes?
                                                             Have you tried agnus castus to relieve hot flashes?
                                                             Has agnus castus been effective in relieving hot flashe
                                                             Have you tried black cohosh to relieve hot flashes?
                                                             Has black cohosh been effective in relieving hot flashe
                                                             Have you tried oil of evening primrose to relieve hot fla
                                                             Has oil of evening primrose been effective in relieving
                                                             Have you tried bioflavanoids to relieve hot flashes?
                                                             Have bioflavanoids been effective in relieving hot flash
                                                             Have you tried wild Mexican yam to relieve hot flashes
                                                             Has wild Mexican yam been effective in relieving hot fl
                                                             Have you tried soy products to relieve hot flashes?
                                                             Have soy products been effective in relieving hot flash
                                                             Have you tried sarsaparilla to relieve hot flashes?
                                                             Has sarsaparilla been effective in relieving hot flashes
                                                             Have you tried chaste tree to relieve hot flashes?
                                                             Has chaste tree been effective in relieving hot flashes?
                                                             Have you tried fennel to relieve hot flashes?
                                                             Has fennel been effective in relieving hot flashes?
                                                             Have you tried Hawthorne to relieve hot flashes?
                                                             Has Hawthorne been effective in relieving hot flashes?
                                                             Have you tried red clover to relieve hot flashes?
                                                             Has red clover been effective in relieving hot flashes?
                                                             Have you tried ginseng to relieve hot flashes?
                                                             Has ginseng been effective in relieving hot flashes?
                                                             Have you tried meditation to relieve your hot flashes?
                                                             If yes, has meditation helped?
                                                             How often do you meditate?
Physiological   Urogenital   Incontinence symptoms


                                                     How often do you leak urine?
                                                     How much leakage do you experience?
                                                     How long does the leaking last?
                                                     Have you experienced involuntary leakage when you c
                                                     How often have you experienced involuntary leakage w
                                                     Have you experienced involuntary leakage when you r
                                                     How often have you experienced involuntary leakage w
                                                     Have you experienced involuntary leakage when you li
                                                     How often have you experienced involuntary leakage w
                                                     Have you experienced involuntary leakage when you b
                                                     How often have you experienced involuntary leakage w
                                                     Have you experienced involuntary leakage of urine wh
                                                     How often have you experienced involuntary leakage w
                                                     Have you experienced involuntary leakage of urine wh
                                                     How often have you experienced involuntary leakage w
                                                     Have you experienced involuntary leakage of urine wh
                                                     How often have you experienced involuntary leakage w
                                                     Have you experienced involuntary leakage when you r
                                                     How often have you experienced involuntary leakage w
                                                     Have you experienced involuntary leakage when you w
                                                     How often have you experienced involuntary leakage w
                                                     Have you experienced involuntary leakage when you a
                                                     How often have you experienced involuntary leakage w
                                                     Have you experienced involuntary leakage during sexu
                                                     How often have you experienced involuntary leakage d
                                                     Have you experienced involuntary leakage when just ly
                                                     How often have you experienced involuntary leakage w
                                                     Do you ever find yourself wet or damp and not realize
                                                     How much fluid do you drink each day?
                                                     How much fluid do you drink in the two hours before yo
                                                     How often do you urinate each day?
                                                     Do you urinate more than 8 times in a 24 hour period?
                                                     Does the need to urinate increase at night?
                                                     Does the need to urinate wake you at night?
                                                     Do you urinate more than two times a night?
                                                     How much has urine leakage affected your ability to do
                                                     How much has urine leakage affected your ability to do
                                                     How much has urine leakage affected your ability to tra
                                                     How much has urine leakage affected your desire to e
                                                     Does leakage have you feeling frustrated?
                                                        Does leakage make you lose your patience?
                                                        Does leakage make you feel discouraged?
                                                        Does leakage make you feel like you are losing contro
                                                        Does leakage make you angry?
                                                        Does leakage make you feel depressed?
                                                        Does leakage make you feel anxious?
                                                        Does leakage make you feel less attractive?
                                                        Are you afraid of leakage?




Physiological   Urogenital   Treatment -incontinence




Physiological   Urogenital   Urinary tract infections




Physiological   Urogenital   Treatment




Physiological   Urogenital   Vaginal infections




Physiological   Urogenital   Vaginal dryness
Physiological   Urogenital         Treatment - vaginal dryness




Physiological   Urogenital         Vaginal discharge




Physiological   Urogenital         Treatment - vaginal discharge


Physiological   Sleep disruption   Symptoms
Do you wake up fresh and rested?
Do you wake up tired?
Do you feel alert during daytime hours?
Do you feel sleepy during the day?
Do you fall asleep even though you are not trying to?
Do you find yourself dozing during the day?
Is your family life affected by your sleep problem?
Is your work affected by your sleep problem?
Do you have difficulty concentrating on things because
Do you have difficulty remembering things because yo
Do you have difficulty doing work around the house be
Do you have difficulty finishing a meal because you are
Do you have difficulty operating a motor vehicle for sho
Do you have difficulty operating a motor vehicle for lon
Do you have difficulty visiting with your friends or famil
Do you have difficulty exercising or participating in a sp
Do you have difficulty watching a movie because you b
Do you have difficulty being as active as you want to b
Do you have difficulty being as active as you want to b
Do you have difficulty being as active as you want to b
Do you have difficulty keeping pace with others your ow
Has your sexual activity been affected because you ar
Has your desire for sex been affected because you are
Has your ability to become sexually aroused been affe
Has your ability to have an orgasm been affected beca
Do you have trouble falling asleep?
Does it take longer than 30 minutes to fall asleep after
Do you drink caffeinated beverages during the day?
How many caffeinated beverages do you drink during
Do you wake up during the night?
How many times do you wake up during the night?
Does this happen every night?
Do you have trouble going back to sleep?
How long does it take to go back to sleep?
Do you awaken at night due to worry?
Do you awaken at night due to need to urinate?
Do you awaken at night due to pain?
Do you awaken at night due to muscle spasms?
Do others awaken you at night?
Have you lost sleep due to frightening or unpleasant n
Have you lost sleep due to worry or stress?
Do you wake up too early?
Do you have trouble going back to sleep if you wake u
Do you go back to sleep?
Do you wake up earlier than 4:00 am?
Do you fall asleep during quiet activities such as readin
Do you have sleep problems more than 3 nights a wee
Do you snore?
Physiological   Sleep disruption       Treatment




                                       Treatment -alternative




Physiological   Skin, hair and nails   Symptoms




Physiological   Skin, hair and nails   Treatment -
Physiological   Joints and muscles   Symptoms




                                                When did the shoulder pain begin?
                                                How often does your shoulder hurt?
                                                How would you describe the severity of the shoulder p
                                                What are the symptoms of the shoulder pain? (Choose
                                                Do you have low back pain?
                                                Does the pain in your back affect your ability to bend o
                                                Does the pain in your back affect your ability to walk?
                                                Does the pain in your back affect your ability to get in a
                                                Can you bend over to pick something up off the floor?
                                                When did the back pain begin?
                                                How often does your back hurt?
                                                How would you describe the severity of the back pain?
                                                What are the symptoms of the back pain? (Choose fro
                                                Do you have pain in your wrists?
                                                Do you have pain in your hip joints?
                                                Have you experienced a sensation of numbness and/o




Physiological   Voice                Symptoms
                             Treatment


Behavior   Sexual activity




                                         Does the change cause you concern?
                                         Does the change please you?
                                         How have you felt about intercourse over the past two
                                         Are you more satisfied than before?
                                         Are you less satisfied than before?
                                         Have you experienced a recent change in sexual desir
                                         Do you have a loss of interest in sexual activities?
                                         Do you feel less sensual?
                                         Do you feel more sensual?
                                         Do you have an increased interest in sexual activities?
                                         Have you experienced a recent loss of arousal such as
                                         Have you experienced an increased level of arousal?
                                         Have you experienced a loss of response recently (we
                                         Have you experienced a greater response recently?
                                         Have you had problems due to pain during intercourse
                                         How long ago did the pain start?




Behavior   Smoking
Behavior   Recreational drug use




Behavior   Alcohol use




Behavior   Diet




                                     cheese
                                     yogurt
                                     butter or other animal fat
                                     cereal
                                     nuts
                                     grains
                                     bread
                                     fried foods
                                   What percentage of your diet is raw fruits and vegetab
                                   What percentage of your diet is red meats?
                                   What percentage of your diet is poultry?
                                   What percentage of your diet is dairy products such as
                                   What percentage of your diet is breads, grains, and ce
                                   Do you add salt to the food you cook?
                                   Do you add salt to the food at the table?
                                   How much water do you drink each day?
                Diet         Weight gain




Behavior        Exercise




                                                    In an average week, how often do you do endurance e
                                                    What type of endurance/aerobic exercise do you do? (
                                                    In an average week, how often do you do resistance e
                                                    What type of resistance exercise do you do? (Choose
                                                    Would you say that your level of exercise is light, mode
                                                    Do you play a sport?
                                                    Which sport(s) do you play? (choose from selection)
                                                    Are you satisfied with your exercise program?
                                                    Do you do any exercises to increase your flexibility?
                                                    Does your job involve silting for a large part of the day?
                                                    Does your job involve any physical activity?
                                                    Do you use the stairs whenever possible?
                                                    Do you experience shortness of breath during exercise
                                                    Do you have pains in your heart and chest with exercis
                                                    Have you had an attack of shortness of breath that com
                                                    Did you know that as women age body fat increases a




Psychological   Well being   Attitude - menopause
                Well being   Attitude - self




Psychological   Anxiety      Symptoms




                                               Do you feel a loss of energy?
                                               Do you have nightmares?
                                               Can you breathe in and out easily?
                                               Do you get feeling of numbness and tingling in your fin
                                               Do your arms and legs shake and tremble?
                                               Do you get headaches frequently?
                                               Are you bothered by stomach aches and indigestion?
                                               Are you bothered by dizzy spells?
                                               Do you have fainting spells?
                                               Are you having trouble with your memory?
                                               Do you feel like you are having more trouble remembe
                                               Are you more forgetful?
                                           Are you having more trouble with mental skills requirin
                                           Are you having trouble focusing and maintaining your a
                                           Is your memory weakening?
                                           Are you having more trouble remembering things and




Psychological   Anxiety        Treatment




Psychological   Irritability   Symptoms




                Irritability
Psychological   Irritability   Treatment



                Depression     Symptoms
                               Treatment
                                        Are you crying more easily than you did before?
                                        Does being with your family bring you pleasure?
                                        Does going out with your friend give you pleasure?
                                        If you are a shopper, do you enjoy shopping?
                                        Are you having less good moods and time of joy?
                                        Are you more withdrawn or isolated?
                                        Are you experiencing more morning fatigue?
                                        Do you feel so fatigues that you can’t et out of bed in th
                                        Are you sleeping less than usual?
                                        Are you sleeping more than usual?
                                        Has your appetite changed since the onset of menopa
                                        Are you eating less?
                                        Are you eating more?
                                        Does food appeal to you?
                                        Are your hand and feet colder than before?
                                        Do you feel less motivated?




Psychological   Spirituality




Environment     Social         Family



                                        How satisfied are you with the sexual activity between
                                        How satisfied are you with how you and your spouse h
                                        How satisfied are you with the similarity of interests be
                                        How satisfied are you with the similarity of lifestyle betw
                                        How satisfied are you with the similarity of temperame
                                        Do you feel isolated in your marriage?
                                        If you are single:
                                        Are you single by choice?
                                        Do you feel isolated because you are single?
                                        Do you have someone to turn to when you need to talk
                                        Do you have someone to turn to when you feel sad?
                                        Do you talk to your family about your menopausal sym
                                        Do you have close family?
                                        Do you see your family often?
                                        Does seeing your family cause you stress?
                                        Do you talk to your family about your menopausal sym
                                        Does being with your family bring you comfort?
                                        Do you have close friends?
                                        Do you see your friends often?
                                        Do you talk to your friends about your menopausal sym
Do your friends provide support to you?
Do you have children?
Are your children still at home?
Are you children getting ready to leave home?
Have you children recently left home?
How do you feel about not having your children at hom
Are your parents still alive?
Are your parents living with you?
Are you responsible for taking care of your parents?
Within the last year have you been hit, slapped, kicked
Within the last year has anyone forced you to have sex
Do you feel emotionally abused by anyone?
Have you had counseling?
Do you drive a car?
Do you consider your driving ability is affected by your
Is your work efficiency/productivity affected by youth m
Do you think other family, friends, and co-workers are
STATUS QUESTION

How would you describe your current menstrual status? Check one box.
          Premenopausal
          Perimenopausal or in menopausal transition (changes in periods)
          Post-menopausal (no period in over 12 months)
How old are you?
Is your menopause (check one box)
          spontaneous
          surgical
          due to chemotherapy or radiation therapy
Have you had a gyn exam in the past year? (If no, link to information)
Have you had a pap smear in the past year? (If no, link to information)
Have you had an abnormal pap smear?
If yes, was it called atrophic?
Have you had a hysterectomy?
If yes, when did you have the surgery?
Have you had your uterus removed?
If yes, when did you have the surgery?
Have you had your ovaries removed?
If yes, when did you have the surgery?
If yes, are you are hormone replacement therapy?
Have you had any breast biopsies?
If yes, was it cancerous?
Have you had a bone density test in the past year? (If no, link to information)
Have you had a blood sugar test in the past year? (If no, link to information)

What is your height?
What is your maximum remembered height?
What is your weight?
What is your maximum remembered weight?
What is your minimum remembered weight since menstruation?

Have you been told you have high blood pressure or are hypertensive?
Did you have this condition before the onset of menopause?
Do you have your blood pressure checked regularly?
Are you on medication for high blood pressure?
Do or did any of your blood relative have high blood pressure? (Choose from list of relatives)
Have you been told that you have had a heart attack?
Did you have your heart attack before or after the onset of menopause?
Have you ever had a cardiogram?
Do or did any of your blood relative have or die from a heart attack? (Choose from list of relatives)
Have you been told that you have had a stroke?
Did you have your stroke before or after the onset of menopause?
Do or did any of your blood relatives have or die from a stroke? (Choose from list of relatives0
Have you been told you have a blood clot?
Did the blood clot occur before or after the onset of menopause?
Were you treated with blood thinners for your blood clot?
Have you had a pulmonary embolism?
Do you have varicose veins?
Do you have problems with bleeding easily from cuts?
Have you been told you have glaucoma?
Did you have this condition before the onset of menopause?
Do or did any of your blood relatives have glaucoma?
Have you been told you have osteoporosis?
Has your height decreased from your tallest remember height?
How much has it decreased?
Have you had a fractured hip?
Have you had a fracture in your spine?
Have you had a bone density study?
What did the results indicate? (Choose from selections)
Have you been told that you have diabetes?
Did you have this condition before the onset of menopause?
Do or did any of your blood relatives have this condition?
If you have diabetes do you control it by diet?
Do you control it by oral medication?
Do you control it by insulin?
Have you been told you have breast cancer?
Did you have this condition before the onset of menopause?
Do or did any of your female blood relatives have this condition?
Do or did they have breast cancer before the age of 50?
Did any of them die due to breast cancer?
Do or did any of your male relatives have breast cancer?
Did any of them die due to breast cancer?
Have you been told you have ovarian cancer?
Did you have this condition before the onset of menopause?
Do or did any of your female blood relatives have this condition?
Do or did they have ovarian cancer before the age of 50?
Did any of them die due to ovarian cancer?
Have you been told you have colorectal cancer?
Did you have this condition before the onset of menopause?
Do or did any of your blood relatives have this condition?
Did any of them die due to colorectal cancer?
Have you been told you have Alzheimer's disease?
Did you have this condition before the onset of menopause?
Do or did any of your blood relatives have this condition?

What was your age at first menstrual period?
Do you still have periods?
Are your periods regular?
Has there been a recent change in how often you have your period?
How many periods have you had in the last year?
Have you missed more than six periods before having one again?
How many days between your periods?
Does your period occur more frequently than every 21 days?
Are there fewer or more days between your periods over the last two years?
Has the number of days between your period increased by more than 5 over the past two years?
Has the number of days between your period decreased by more than 5 over the past two years?
Has there been a recent change in the length of your period?
How many days do your periods last?
Has the number of days of your period increased over the last two years?
Has the number of days of your period decreased over the last two years?
Are your periods longer than 8 days?
Is your period heavier than it was in the past? (Scale)
If yes, how much heavier is your period? (Scale)
Is your period lighter than it was in the past? (scale)
If yes, how much lighter than it was in the past?
Do you feel you have a problem with your period?
Have you discussed your concerns about your period with your practitioner?
Do you have problems with PMS (bloating, mood swings, anger) prior to your period?
Do you have spotting or bleeding in between periods?
How often does this happen?
How long does the spotting last?
What color is the spotting?
Do you have pain with your periods?
How severe is the pain?
How long does the pain last?
Where is the pain located?
What type of pain do you experience with your periods?
What do you do to relieve the pain?
Is your pain treatment effective?

Have you ever been pregnant?
Have you had children?
How many children have you given birth to?
How old were you when you gave birth to your first child?
How old were you when you gave birth to your last child?
Did you have any complications during pregnancy?
Are you using birth control?
What method of birth control are you using?

Have you experienced hot flashes or sudden intense waves of heat?
At what age did you first experience a hot flash?
Have you had hot flashes due to any other reason than approaching menopause?
How would you rate the severity of your hot flashes?
Does the hot flash cause you to sweat?
Do you sweat enough to make your clothes damp?
Does the hot flash cause you to flush?
Do you have a chill after the hot flash?
Does your heart beat faster during a hot flash?
Do you feel butterflies in your chest or stomach?
Does your skin feel like its crawling?
How long do the hot flashes last?
Do the hot flashes last longer than one minute?
Do the hot flashes come in groups or waves?
How many times a day do you experience hot flashes?
Is there a time of day when you have more hot flashes?
What time of day do you have more hot flashes?
Is there a time of day when you have fewer hot flashes?
What times of day do you have the fewest hot flashes?
Do you have hot flashes at night?
Do you wake up due to hot flashes?
If you sleep with someone, do your hot flashes cause them to awaken?
Do your night sweats/hot flashes cause your bed linen to become damp?
Do your night sweats/hot flashes cause your bed linen to become soaked?
Have your hot flashes impacted on the quality of your sleep?
Have your hot flashes impacted on the duration of your sleep?
Does your heart beat faster during a hot flash?
How long have you been experiencing hot flashes?
When did you first experience your first hot flash?
Did you know what was happening when you experienced your first hot flash?
What emotion did you feel when you experienced your first hot flash?
Do you feel anxious when you have a hot flash?
Do you feel uncomfortable when you have a hot flash?
Do you feel annoyed when you have a hot flash?
Do you feel embarrassed when you have a hot flash?
Do you feel angry when you have a hot flash?
Do you feel depressed when you have a hot flash?
Do you feel debilitated when you have a hot flash?
Have your hot flashes increased in intensity since your first hot flash?
Have your hot flashes increased in duration since your first hot flash?
Have your hot flashes increased in frequency since your first hot flash?
Have your hot flashes decreased in intensity since your first hot flash?
Have your hot flashes decreased in duration since your first hot flash?
Have your hot flashes decreased in frequency since your first hot flash?
Have your hot flashes remained the same?
Has your attitude changed about your hot flashes?
Have you become more accepting of the hot flashes?
Have you become less accepting of the hot flashes?
Has your quality of life suffered due to your hot flashes?
Does being in a confined space cause you to have a hot flash?
Do you experience more hot flashes when in a confined space?
Does being in the heat cause you to have a hot flash?
Do you experience more hot flashes when it is hot?
Does being in humidity cause you to have a hot flash?
Do you experience more hot flashes when it is humid?
Does eating spicy food cause you to have a hot flash?
Do you experience more hot flashes after eating spicy food?
Are there other types of foods that cause you to have hot flashes?
If yes, select the food groups that cause you to have hot flashes.
Does drinking caffeinated beverages cause you to have a hot flash?
Do you experience more hot flashes after drinking caffeinated beverages?
Does drinking alcohol cause you to have a hot flash?
Do you experience more hot flashes after drinking alcohol?
If you smoke cigarettes or use tobacco products, do they cause you to have a hot flash?
Did you know that smokers are at an increased risk for moderate to severe hot flashes?
Did you know that smokers are at an increased risk for frequent hot flashes?

Do you do feel you need to do something to relieve your hot flashes?
Do you do anything to relieve your hot flashes?
Have you tried changing your diet to relieve your hot flashes?
If yes, have you removed spicy foods from your diet?
Have you tried removing other foods from your diet?
If yes, select the types of foods you have removed from your diet.
Have you tried removing caffeinated beverages from your diet?
If yes, has it helped relieve your hot flashes?
Have you tried reducing or eliminating alcohol from your diet?
If yes, has it helped relieve your hot flashes?
Have you tried to stop smoking to relieve your hot flashes?
If yes, has it helped relieve your hot flashes?
Have you sought medical attention for your hot flashes?
Do you take Hormone Replacement Therapy (HRT)?
What type of HRT are you taking?
How long have you been taking HRT?
Have you changed the type of HRT you have used?
Has the HRT helped relieve your hot flashes?
Did you take HRT in the past and then stop?
Have you restarted HRT?
Why did you stop HRT?

Have you tried alternative treatments for hot flashes?
Do you believe alternative treatments are effective in relieving hot flashes?
Would you like information on alternative treatments for relieving hot flashes?
Have you tried botanical therapies to relieve hot flashes?
Would you like information on herbal therapies for relieving hot flashes?
Have you tried Vitamin C with bioflavanoids to relieve hot flashes?
Has Vitamin C with bioflavanoids been effective in relieving hot flashes?
Have you tried dong quai to relieve hot flashes?
Has dong quai been effective in relieving hot flashes?
Have you tried agnus castus to relieve hot flashes?
Has agnus castus been effective in relieving hot flashes?
Have you tried black cohosh to relieve hot flashes?
Has black cohosh been effective in relieving hot flashes?
Have you tried oil of evening primrose to relieve hot flashes?
Has oil of evening primrose been effective in relieving hot flashes?
Have you tried bioflavanoids to relieve hot flashes?
Have bioflavanoids been effective in relieving hot flashes?
Have you tried wild Mexican yam to relieve hot flashes?
Has wild Mexican yam been effective in relieving hot flashes?
Have you tried soy products to relieve hot flashes?
Have soy products been effective in relieving hot flashes?
Have you tried sarsaparilla to relieve hot flashes?
Has sarsaparilla been effective in relieving hot flashes?
Have you tried chaste tree to relieve hot flashes?
Has chaste tree been effective in relieving hot flashes?
Have you tried fennel to relieve hot flashes?
Has fennel been effective in relieving hot flashes?
Have you tried Hawthorne to relieve hot flashes?
Has Hawthorne been effective in relieving hot flashes?
Have you tried red clover to relieve hot flashes?
Has red clover been effective in relieving hot flashes?
Have you tried ginseng to relieve hot flashes?
Has ginseng been effective in relieving hot flashes?
Have you tried meditation to relieve your hot flashes?
If yes, has meditation helped?
How often do you meditate?
Have you tried homeopathic treatments to relieve your hot flashes?
Has it been effective in relieving your hot flashes?
Has sexual activity increased or worsened the frequency of your hot flashes?
Has sexual activity decreased or lessened the frequency of your hot flashes?
Has sexual activity increased or worsened the duration of your hot flashes?
Has sexual activity decreased or lessened the duration of your hot flashes?
Have you tried acupuncture to relieve your hot flashes?
Has acupuncture helped to relieve your hot flashes?
Have yopu tried chiropractic therapy to relieve your hot flashes?
Has chiropractic therapy helped to relieve your hot flashes?
Have you tried relaxation therapy to relieve your hot flashes?
Has relaxation therapy helped relieve your hot flashes?

Do you feel you have developed a urinary incontinence or urine leakage problem with the onset of perimenopause?
Have you been diagnosed with a urinary incontinence or leakage problem?
Did you have a leakage problem prior to the onset of menopause?
How often do you leak urine?
How much leakage do you experience?
How long does the leaking last?
Have you experienced involuntary leakage when you change positions from sitting or standing?
How often have you experienced involuntary leakage when changing positions from sitting or standing?
Have you experienced involuntary leakage when you run?
How often have you experienced involuntary leakage when you run?
Have you experienced involuntary leakage when you lift something heavy?
How often have you experienced involuntary leakage when you lift something heavy?
Have you experienced involuntary leakage when you bend over?
How often have you experienced involuntary leakage when you bend over?
Have you experienced involuntary leakage of urine when you laugh?
How often have you experienced involuntary leakage when you laugh?
Have you experienced involuntary leakage of urine when you cough?
How often have you experienced involuntary leakage when you cough?
Have you experienced involuntary leakage of urine when you sneeze?
How often have you experienced involuntary leakage when you sneeze?
Have you experienced involuntary leakage when you reach over your head?
How often have you experienced involuntary leakage when you reach over your head?
Have you experienced involuntary leakage when you wash your hands?
How often have you experienced involuntary leakage when you wash your hands?
Have you experienced involuntary leakage when you are running water?
How often have you experienced involuntary leakage when you are running water?
Have you experienced involuntary leakage during sexual intercourse?
How often have you experienced involuntary leakage during sexual intercourse?
Have you experienced involuntary leakage when just lying down?
How often have you experienced involuntary leakage when lying down?
Do you ever find yourself wet or damp and not realize you had an accident?
How much fluid do you drink each day?
How much fluid do you drink in the two hours before you go to bed?
How often do you urinate each day?
Do you urinate more than 8 times in a 24 hour period?
Does the need to urinate increase at night?
Does the need to urinate wake you at night?
Do you urinate more than two times a night?
How much has urine leakage affected your ability to do household chores?
How much has urine leakage affected your ability to do physical activities?
How much has urine leakage affected your ability to travel by car or bus more than 30 minutes?
How much has urine leakage affected your desire to engage in social activities?
Does leakage have you feeling frustrated?
Does leakage make you lose your patience?
Does leakage make you feel discouraged?
Does leakage make you feel like you are losing control?
Does leakage make you angry?
Does leakage make you feel depressed?
Does leakage make you feel anxious?
Does leakage make you feel less attractive?
Are you afraid of leakage?
Are you afraid of smelling bad because of leakage
Are you afraid of staining at work or other places?
Do you have to change your clothes during the day due to leakage?
If you use protection, do you feel embarrassed by the need to wear it?
Are you afraid of leakage during sexual intercourse?
Has the leaking caused you to change your sexual behavior?
Are you afraid others might notice your leakage problem?
Do you take protection (pads/diapers) with you when you are going out?

Have you tried any self help techniques to control leakage?
Have you tried to drink fluids less often?
Have you tried to go to the bathroom more often?
Have you tried to stay near a bathroom?
Have you used pads/diapers?
Have you sought medical attention for the leakage problem?
Have you tried bladder training to control leakage?
Have you tried pelvic muscle exercises to control leakage?
Have you tried medication to control leakage?
Have you had surgery to control leakage?
Have you tried electrical stimulation to control leakage?

Have you been getting urinary tract infections since the onset of perimenopause?
Did you get urinary tract infections before the onset of perimenopause?
How many urinary tract infections have you had since the onset of perimenopause?
How often do you get urinary tract infections?
Does it sting when you urinate?
Does it burn when you urinate?
Do you feel an increased need to urinate?

Have you sought medical attention to treat your urinary tract infections?
How are you urinary tract infections treated? (Choose from selections)
Have you tried HRT to relieve urinary tract and infections?


Have you been getting vaginal infections since the onset of perimenopause?
Did you get vaginal infections before the onset of perimenopause?
How many vaginal infections have you had since the onset of perimenopause?
How often do you get vaginal infections?
Do you seek medical attention for vaginal infections?
How are your vaginal infections treated?
Have you been experiencing vaginal dryness since the onset of perimenopause?
Is dryness noticed during sexual intercourse?
Do you have difficulty with sexual intercourse due to vaginal dryness?
Do you do feel you need to do something to relieve your vaginal dryness??
Do you do anything to relieve your vaginal dryness?
Do you bleed after a pelvic exam?

Have you sought medical attention for your vaginal dryness?
Has any medical treatment been prescribed?
Have you tried alternative treatments for vaginal dryness?
Do you believe alternative treatments are effective in relieving vaginal dryness?
Would you like information on alternative treatments for relieving vaginal dryness?
Have you tried herbal therapies to relieve vaginal dryness?
Would you like information on herbal therapies for relieving vaginal dryness?
Have you tried oil of evening primrose to relieve vaginal dryness?
Has oil of evening primrose been effective in relieving vaginal dryness?
Have your tried Vitamin E to relieve vaginal dryness?
Has Vitamin E been effective in relieving vaginal dryness?
Have you tried flax seed oil to relieve vaginal dryness?
Has flax seed oil been effective in relieving vaginal dryness?

Have you started having vaginal discharge since the onset of menopause?
How often do you have a discharge?
How much discharge do you have?
What type of discharge do you have? (Choose from selections)
Does the discharge smell?
Do you ever get burning sensations in your vagina?
How often do you experience the burning sensation?
How severe is the burning?
Is the pain severe enough to seek medical attention?
Have you tried vaginal creams to relieve the burning?
Have you tried vaginal estrogens to relieve the burning?
Does sexual intercourse cause the burning?
Do you experience vaginal itching?
How severe is the itching?
How often do you experience the itching sensation?
Does sexual intercourse initiate or worsen the itching?
Is the itching severe enough to seek medical attention?

Have you tried vaginal creams to relieve the itching?
Have you sought medical attention to relieve the itching?

Have you been experiencing sleeping problems since the onset of perimenopause?
Have you always had sleeping problems?
Have you noticed a change in your sleeping habits?
Do you feel you are sleeping less?
Do you feel you are sleeping more?
Do you enjoy sleeping?
Do you feel sleeping is a waste of time?
How many hours do you sleep?
What do you feel is the ideal amount of sleep?
Do you sleep less than 4 hours?
Do you sleep less than 2 hours?
What is your normal bedtime?
What is your normal rise time?
Overall, how do you rate your sleep quality?
Do you wake up fresh and rested?
Do you wake up tired?
Do you feel alert during daytime hours?
Do you feel sleepy during the day?
Do you fall asleep even though you are not trying to?
Do you find yourself dozing during the day?
Is your family life affected by your sleep problem?
Is your work affected by your sleep problem?
Do you have difficulty concentrating on things because you are sleepy or tired?
Do you have difficulty remembering things because you are sleepy or tired?
Do you have difficulty doing work around the house because you are sleepy or tired?
Do you have difficulty finishing a meal because you are sleepy or tired?
Do you have difficulty operating a motor vehicle for short distances because you are sleepy or tired?
Do you have difficulty operating a motor vehicle for long distances because you are sleepy or tired?
Do you have difficulty visiting with your friends or family because you are sleepy or tired?
Do you have difficulty exercising or participating in a sporting activity because you are too sleepy or tired?
Do you have difficulty watching a movie because you become too sleepy or tired?
Do you have difficulty being as active as you want to be in the evening because you are too sleepy or tired?
Do you have difficulty being as active as you want to be in the morning because you are too sleepy or tired?
Do you have difficulty being as active as you want to be in the afternoon because you are too sleepy or tired?
Do you have difficulty keeping pace with others your own age because you are too sleepy or tired?
Has your sexual activity been affected because you are sleepy or tired?
Has your desire for sex been affected because you are sleepy or tired?
Has your ability to become sexually aroused been affected because you are too sleepy or tired?
Has your ability to have an orgasm been affected because you are too sleepy or tired?
Do you have trouble falling asleep?
Does it take longer than 30 minutes to fall asleep after going to bed?
Do you drink caffeinated beverages during the day?
How many caffeinated beverages do you drink during the day?
Do you wake up during the night?
How many times do you wake up during the night?
Does this happen every night?
Do you have trouble going back to sleep?
How long does it take to go back to sleep?
Do you awaken at night due to worry?
Do you awaken at night due to need to urinate?
Do you awaken at night due to pain?
Do you awaken at night due to muscle spasms?
Do others awaken you at night?
Have you lost sleep due to frightening or unpleasant nightmares?
Have you lost sleep due to worry or stress?
Do you wake up too early?
Do you have trouble going back to sleep if you wake up too early?
Do you go back to sleep?
Do you wake up earlier than 4:00 am?
Do you fall asleep during quiet activities such as reading or watching TV?
Do you have sleep problems more than 3 nights a week?
Do you snore?
Has anyone told you that you snore?
If you snore, does your snoring awaken you?
Do you wake up during the night or in the morning with headaches?
Do you nap during the day?
Do you nap every day?
How many times a day do you nap?
How long do you nap?
Does the nap interfere with your being able to fall asleep at night?
Do you feel rested after a nap?

If you have sleep problems, have you sought medical attention?
Where have you sought assistance? (Choose from selection)
Do you take any kind of medication to help you sleep?
How many nights a week do you take medication to help you sleep?
What type of medication do you take to help you sleep?
Is the medication over the counter?
Is the medication prescription?
Do you take alcohol to help you sleep?
Have you tried alternative treatments for sleep problems?
Do you believe alternative treatments are effective in treating sleep problems due to menopause?
Would you like information on alternative treatments for treating sleep problems due to menopause?
Have you tried herbal therapies to treat sleep problems due to menopause?
Would you like information on herbal therapies for treating sleep problems due to menopause?
Have you tried valerian to help you sleep?
Has valerian been effective in helping you sleep?
If you are fatigued due to sleep problems, have you tried ginger?
Has ginger been effective in relieving your fatigue?
If you are fatigued due to sleep problems, have you tried ginseng?
Has ginseng been effective in relieving your fatigue?
If you are fatigued due to sleep problems, have you tried blessed thistle?
Has blessed thistle been effective in relieving your fatigue?
If you are fatigued due to sleep problems, have you tried cayenne pepper?
Has cayenne pepper been effective in relieving your fatigue?

Since the onset of perimenopause:
Have you experienced a change in the condition of your skin?
Have you developed acne?
Has your skin become more oily?
Has your skin become drier?
Does you skin feel cooler to the touch?
Is your skin very pale?
Does your skin feel like it had lost its firmness and fullness?
Are you noticing more wrinkles around your eyes and mouth?
Do you have cracking at the corners of your mouth?
Have you developed rough dry red pimply skin on your upper arms and thighs?
Do you have poor skin tone on your arms and legs?
Have you started to grow more facial hair?
Do you have moor hair on your face now than you did than at the onset of menopause?
Has the texture and condition of your hair changed?
Have you experienced poor hair growth?
Has your pubic hair thinned?
Has the condition of your nails been affected?
Do you have white spots on your nails?
Do you have split and brittle nails?

Have you sought medical attention for your skin, hair or nail problems?
Have you tried alternative treatments for skin changes?
Do you believe alternative treatments are effective in treating skin changes due to menopause?
Would you like information on alternative treatments for treating skin changes due to menopause?
Have you tried herbal therapies to treat skin changes due to menopause?
Would you like information on herbal therapies for treating skin changes due to menopause?
Have you tried oil of evening primrose to treat skin changes due to menopause?
Has oil of evening primrose been effective in treating skin changes?
Have your tried Vitamin E to treat skins changes due to menopause?
Has Vitamin E been effective in treating skin changes?
Have you tried flax seed oil to treat skin changes?
Has flax seed oil been effective in treating skin changes due to menopause?

Since the onset of perimenopause:
Are you having more aches and pains?
Do you have neck pain?
Can you turn your head from side to side?
Can you bend your head back and forth?
When did the neck pains begin?
How often does your neck hurt?
How would you describe the severity of the neck pain? (Choose from selections)
What are the symptoms of the neck pain? (Choose from selections)
Do you have pain in your shoulders?
Does the pain in your shoulders prevent you from being able to lift things?
Does the pain in your shoulders prevent you from raising your arms?
When did the shoulder pain begin?
How often does your shoulder hurt?
How would you describe the severity of the shoulder pain? (Choose from selections)
What are the symptoms of the shoulder pain? (Choose from selections)
Do you have low back pain?
Does the pain in your back affect your ability to bend over?
Does the pain in your back affect your ability to walk?
Does the pain in your back affect your ability to get in and out of the car?
Can you bend over to pick something up off the floor?
When did the back pain begin?
How often does your back hurt?
How would you describe the severity of the back pain? (Choose from selections)
What are the symptoms of the back pain? (Choose from selections)
Do you have pain in your wrists?
Do you have pain in your hip joints?
Have you experienced a sensation of numbness and/or tingling in your arms or legs?
Do you feel like you are having more twitches and spasms?
Do you have less muscle strength?
Have you noticed a recent loss of height?
Have you noticed increased curvature of the spine?
Has the pain in your joints impacted on your ability to do your job?
Have you been diagnosed with arthritis since the onset of menopause?
Did you have arthritis before menopause?

Have you noticed a change in your voice since the onset of perimenopause?
Has your voice become deeper?
Has your voice become more masculine sounding?
Does the change in your voice bother you?
Does the voice change make you sound sexy?

Have you sought medical attention to address the voice change?
Did you have your hormone levels checked?

Are you currently sexually active?
If yes, are you having sex with
    a man (men)
    a woman (women)
    both men and women
How long have you been with your current sexual partner?
Do you feel you are in a committed, mutually monogamous relationship?
In the past have you had sex with
    a man (men)
    a woman (women)
    both men and women
How often have you and your partner had intercourse in the past week?
Ten years ago, how often a week did you engage in sexual activity?
Is this more often than in the past?
Is this less often in the past?
Does the change cause you concern?
Does the change please you?
How have you felt about intercourse over the past two years? (Choose from selection)
Are you more satisfied than before?
Are you less satisfied than before?
Have you experienced a recent change in sexual desire?
Do you have a loss of interest in sexual activities?
Do you feel less sensual?
Do you feel more sensual?
Do you have an increased interest in sexual activities?
Have you experienced a recent loss of arousal such as tingling in breast and genitals?
Have you experienced an increased level of arousal?
Have you experienced a loss of response recently (weaker or no orgasm)?
Have you experienced a greater response recently?
Have you had problems due to pain during intercourse in the past two years?
How long ago did the pain start?
Is the pain due to reduced lubrication?
Is the pain associated with penetration?
Do you have bleeding with intercourse?
Have you had sexually transmitted infections?
What type of infections have you had? (Choose from selections)
Have you had sexually transmitted infections?
Do you have concerns about your sex life?
Do you believe you have some form of sexual dysfunction?
Are you having sexual difficulties at this time?
Have you talked to your practitioner about your concerns?
Does your practitioner ask you questions about your sex life?
Do you feel comfortable talking to your practitioner about your sexual activity?
Has your practitioner taken a sexual history?

Do you currently smoke cigarettes?
Do you currently smoke cigars?
Do you use any other tobacco products?
How much do you smoke each day?
At what age did you start smoking?
Do you want to quit smoking?
Have you ever smoked?
If so, at what age did you start
At what age did you stop?
How much did you smoke each day?

Do you use recreational drugs?
If so, what types of drugs?
How often do you use them?
Do you use recreational drugs to relieve your menopausal symptoms?

Do you drink alcohol?
How many drinks do you have each week?
Do you use alcohol to relieve your menopausal symptoms?
Have you ever tried to cut down on your alcohol use?
Do you ever feel guilty about the amount you drink?
Do you ever have a drink to get you going in the morning?

Are you a vegan (only eat vegetable products)?
Are you a vegetarian (no meat, poultry or fish)?
Are you an omnivore (eat all types of food)?
In a week how many portions do you have of the following
   green vegetables
   salads
   red meat
   poultry
   fish
   fruits
   milk
   cheese
   yogurt
   butter or other animal fat
   cereal
   nuts
   grains
   bread
   fried foods
What percentage of your diet is raw fruits and vegetables?
What percentage of your diet is red meats?
What percentage of your diet is poultry?
What percentage of your diet is dairy products such as milk, cheese, and yogurt?
What percentage of your diet is breads, grains, and cereals?
Do you add salt to the food you cook?
Do you add salt to the food at the table?
How much water do you drink each day?
Do you eat more frequently under stressful conditions?
Do you have cravings?
Have you noticed that you crave carbohydrates more since onset of perimenopause?
Do you take any food supplements?
Do you take additional calcium?
Do you take daily vitamins?
What type of vitamins do you take? (Choose)
Do you think the vitamins make a difference in how you feel?

Have you gained weight since the onset of menopause?
How much more do you weigh now than you did before you started menopause?
Has your eating pattern remained the same since you started menopause?
Has your exercise pattern remained the same since you started menopause?
Did you know that every year after the age of 40 your metabolism slows down>
Did you know that weight gained after menopause all goes around the middle of the body instead of being distributed all over th
Are you on hormone replacement therapy?

Did you exercise before the onset of menopause?
Is so, how many years have you been exercising? (scale)
If yes, has the frequency of your exercise increased or decreased?
If yes, has the duration of your exercise increased or decreased?
Are you currently doing some form of exercise?
Did you start exercising within the past two years?
Is exercising important to you?
Do you feel fit?
Do you exercise to relieve stress?
Do you feel exercise has helped to relieve your stress?
Do you exercise to lose weight?
Do you feel exercise has helped you to lose weight?
Do you exercise to maintain weight?
Do you feel exercise has helped you maintain weight?
Are you exercising to reduce your risk of osteoporosis?
In an average week, how often do you do endurance exercise for more than 30 minutes?
What type of endurance/aerobic exercise do you do? (Choose from selections)
In an average week, how often do you do resistance exercise?
What type of resistance exercise do you do? (Choose from selections)
Would you say that your level of exercise is light, moderate or heavy?
Do you play a sport?
Which sport(s) do you play? (choose from selection)
Are you satisfied with your exercise program?
Do you do any exercises to increase your flexibility?
Does your job involve silting for a large part of the day?
Does your job involve any physical activity?
Do you use the stairs whenever possible?
Do you experience shortness of breath during exercise?
Do you have pains in your heart and chest with exercise?
Have you had an attack of shortness of breath that comes on after you exercise?
Did you know that as women age body fat increases and lean muscle mass decreases?
Did you know that endurance training can offset increases in body fat and loss of lean muscle?
Did you know that resistance training can decrease body fat and preserve bone mass density?
Did you know that active women have fewer and less distressful menopausal symptoms overall when compared to inactive wom

How would you rate your knowledge of the symptoms of menopause?
How would you rate your knowledge of possible treatments for symptoms of menopause?
How do you get your information about menopause? (Choose from selection)
Do you associate menopause with getting old?
Do you associate menopause with a loss of fertility?
Do you associate menopause with a loss of youth?
Do you view menopause as giving you freedom from having to worry about pregnancy?
Do you view menopause as giving you sexual freedom?
Do you view menopause as a passageway to a new way of life?
Do you feel HRT is appropriate for some women?
Do you support the use of HRT?
Do you support alternative treatments for menopause?
Are you willing to experiment with different approaches to manage your menopausal symptoms?
Do you think menopause includes unpleasant diseases or symptoms that need treatment?
Do you agree with the statement "I don't have time for menopause."?
Is it important for you to be actively involved in your own symptom management?
Do you feel you can manage your menopausal symptoms on your own?
Do you prefer to go to a health care practitioner and have them tell you what to do?
Do your symptoms interfere with your life?
Are your symptoms driving you crazy?

Do you feel you are still sexually attractive?
Do you feel you will become less sexually attractive as you grow older?
Are you satisfied with your physical appearance?
Do you feel confident in your appearance?
Do you feel you are or look overweight?
Do you feel you are or look underweight?
Do you feel you look old for your age?
Do you feel your breasts are shrinking and sagging?
To what extent does this bother you?
Is your hair thinning?
To what extent does this bother you?

Have you felt more anxious and nervous since you started experiencing menopausal symptoms?
Does the thought of going through menopause make you anxious?
Do any of your menopausal symptoms make you anxious?
If so, which one(s)? (Choose from selection)
Do you have a sense of foreboding about the future?
Are you afraid for no reason at all?
Do you get upset easily or feel panicky?
Do you cry more easily or more often?
Do you feel like you are falling apart?
Do you feel that everything is all right and nothing bad will happen?
Do you feel weak and get tired easily?
Do you feel a loss of energy?
Do you have nightmares?
Can you breathe in and out easily?
Do you get feeling of numbness and tingling in your fingers and toes?
Do your arms and legs shake and tremble?
Do you get headaches frequently?
Are you bothered by stomach aches and indigestion?
Are you bothered by dizzy spells?
Do you have fainting spells?
Are you having trouble with your memory?
Do you feel like you are having more trouble remembering names?
Are you more forgetful?
Are you having more trouble with mental skills requiring logic and problem solving?
Are you having trouble focusing and maintaining your attention?
Is your memory weakening?
Are you having more trouble remembering things and events?
Do you find yourself caring less about things that used to matter to you?
Have you recently forgotten the location of car key or eyeglasses?
Have you missed an appointment that you didn't remember?
Have you lost the end of a thought when speaking or writing?
Are you experiencing more confusion?
Are your hands and feet colder than before?
Do you have a busy lifestyle?
Have you taken a vacation in the past year?
Can you relax easily when you have time off?
Have you ever felt the need to take tranquilizers?

Do you feel you need treatment for your anxiety symptoms?
Have you tried to treat your anxiety?
Have you sought medical treatment for your anxiety?
Have you tried deep breathing exercises to relieve your anxiety?
Has deep breathing helped relieve your anxiety?
Have you tried relaxation exercise to relieve your anxiety?
Have relaxation exercises relieved your anxiety?
Have you tried yoga to relieve your anxiety?
Has yoga worked to relieve your anxiety?
Have you tried any herbal therapies to relieve your anxiety?
Have any herbal therapies helped relieve your anxiety?
Have you tried to counseling to relieve your anxiety?
Has counseling been effective in relieving your anxiety
have you tired group therapy to relieve your anxiety?
Has group therapy been effective in relieving your anxiety?
Have you tried any medications to relieve your anxiety?
Have the medications helped relieve you anxiety?
Are you on hormone replacement therapy?

Do you feel more irritable than you did before experiencing menopause?
Do you feel impatient with people?
Do you lose your temper and shout at others?
Do people upset you so that you feel like slamming doors?
Do you have uncontrollable rages?
Do you lose control and hit or hurt someone?

Have you sought medical attention for your irritability?
Have you tried self help techniques for your irritability?


Have you felt depressed since you started experiencing menopausal symptoms?
Have you been diagnosed with depression?
Does the thought of going through menopause depress you?
Do any of your menopausal symptoms make you feel depressed?
If so, which ones?
Is your mood low, less upbeat or less positive?
Do you feel less outgoing?
Are you crying more easily than you did before?
Does being with your family bring you pleasure?
Does going out with your friend give you pleasure?
If you are a shopper, do you enjoy shopping?
Are you having less good moods and time of joy?
Are you more withdrawn or isolated?
Are you experiencing more morning fatigue?
Do you feel so fatigues that you can’t et out of bed in the morning?
Are you sleeping less than usual?
Are you sleeping more than usual?
Has your appetite changed since the onset of menopause?
Are you eating less?
Are you eating more?
Does food appeal to you?
Are your hand and feet colder than before?
Do you feel less motivated?
Are you having trouble remembering where you left your car keys?
Do you feel your memory is weakening?
Do you feel periods of hopelessness?
Have you contemplated suicide while experiencing menopause?
Have you been violent or aggressive while experiencing menopause?

Are you a deeply religious person?
Do you attend regular services?
Does your faith bring you comfort in times of stress?
Are you a deeply spiritual person?
Does you spirituality bring you comfort in times of stress?

What is your marital status?
If you are married:
How satisfied are you with the amount of time spent with your spouse?
How satisfied are you with the communication between you and your spouse?
How satisfied are you with the sexual activity between you and your spouse?
How satisfied are you with how you and your spouse handle financial matters?
How satisfied are you with the similarity of interests between you and your spouse?
How satisfied are you with the similarity of lifestyle between you and your spouse?
How satisfied are you with the similarity of temperament between you and your spouse?
Do you feel isolated in your marriage?
If you are single:
Are you single by choice?
Do you feel isolated because you are single?
Do you have someone to turn to when you need to talk?
Do you have someone to turn to when you feel sad?
Do you talk to your family about your menopausal symptoms?
Do you have close family?
Do you see your family often?
Does seeing your family cause you stress?
Do you talk to your family about your menopausal symptoms?
Does being with your family bring you comfort?
Do you have close friends?
Do you see your friends often?
Do you talk to your friends about your menopausal symptoms?
Do your friends provide support to you?
Do you have children?
Are your children still at home?
Are you children getting ready to leave home?
Have you children recently left home?
How do you feel about not having your children at home? (Choose from selections)
Are your parents still alive?
Are your parents living with you?
Are you responsible for taking care of your parents?
Within the last year have you been hit, slapped, kicked or physically abused?
Within the last year has anyone forced you to have sexual activity?
Do you feel emotionally abused by anyone?
Have you had counseling?
Do you drive a car?
Do you consider your driving ability is affected by your menopausal symptoms?
Is your work efficiency/productivity affected by youth menopausal symptoms?
Do you think other family, friends, and co-workers are aware of a change in your behavior due to menopause?
rimenopause?
being distributed all over the body?




 compared to inactive women?

								
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