Menopause Questionnaire Symptoms of Menopause Email Address * example@example.com Name * Age * Country Of Residence * I have not had a menstrual cycle in the last 12 months. (In menopause) * Yes No I had a hysterectomy (removal of the uterus) operation/surgery * No Yes Both ovaries were removed I don’t know One ovary was removed If you have answered “yes” to the question above, how many years ago did you have the surgery/operation? * If you had a hysterectomy, what was the reason? * Symptoms Of Menopause I have hot flashes * Not at all 1 2 3 Extremely 4 1 is Not at all, 4 is Extremely I have night sweats * Not at all 1 2 3 Extremely 4 1 is Not at all, 4 is Extremely I have difficulty getting to sleep * Not at all 1 2 3 Extremely 4 1 is Not at all, 4 is Extremely I have difficulty staying asleep * Not at all 1 2 3 Extremely 4 1 is Not at all, 4 is Extremely I get heart palpitations or a sensation of butterflies in my chest or stomach * Not at all 1 2 3 Extremely 4 1 is Not at all, 4 is Extremely I feel like my skin is crawling or itching * Not at all 1 2 3 Extremely 4 1 is Not at all, 4 is Extremely I feel more tired than usual * Not at all 1 2 3 Extremely 4 1 is Not at all, 4 is Extremely I have difficulty concentrating * Not at all 0 1 2 3 Extremely 4 0 is Not at all, 4 is Extremely My memory is poor * Not at all 0 1 2 3 Extremely 4 0 is Not at all, 4 is Extremely I am more irritable than usual * Not at all 0 1 2 3 Extremely 4 0 is Not at all, 4 is Extremely I feel more anxious than usual * Not at all 0 1 2 3 Extremely 4 0 is Not at all, 4 is Extremely I have more depressed moods * Not at all 0 1 2 3 Extremely 4 0 is Not at all, 4 is Extremely I am having mood swings * Not at all 0 1 2 3 Extremely 4 0 is Not at all, 4 is Extremely I have crying spells * Not at all 0 1 2 3 Extremely 4 0 is Not at all, 4 is Extremely I have headaches * Not at all 0 1 2 3 Extremely 4 0 is Not at all, 4 is Extremely I need to urinate more often than usual * Not at all 0 1 2 3 Extremely 4 0 is Not at all, 4 is Extremely I leak urine Not at all 1 2 3 Extremely 4 1 is Not at all, 4 is Extremely I have pain or burning when urinating * Not at all 0 1 2 3 Extremely 4 0 is Not at all, 4 is Extremely I have bladder infections * Not at all 1 2 3 Extremely 4 1 is Not at all, 4 is Extremely I have uncontrollable loss of stool or gas * Not at all 1 2 3 Extremely 4 1 is Not at all, 4 is Extremely My vagina is dry * Not at all 1 2 3 Extremely 4 1 is Not at all, 4 is Extremely I have vaginal itching * Not at all 1 2 3 Extremely 4 1 is Not at all, 4 is Extremely I have an abnormal vaginal discharge * Not at all 1 2 3 Extremely 4 1 is Not at all, 4 is Extremely I have vaginal infections * Not at all 1 2 3 Extremely 4 1 is Not at all, 4 is Extremely I have pain during intercourse * Not at all 1 2 3 Extremely 4 1 is Not at all, 4 is Extremely I have bleeding after intercourse * Not at all 1 2 3 Extremely 4 1 is Not at all, 4 is Extremely I lack desire or interest in sexual activity * Not at all 1 2 3 Extremely 4 1 is Not at all, 4 is Extremely I have difficulty achieving orgasm * Not at all 1 2 3 Extremely 4 1 is Not at all, 4 is Extremely My opportunity for sexual activity is limited * Not at all 1 2 3 Extremely 4 1 is Not at all, 4 is Extremely My stomach feels like it’s bloated or I’ve gained weight * Not at all 1 2 3 Extremely 4 1 is Not at all, 4 is Extremely I have breast tenderness * Not at all 1 2 3 Extremely 4 1 is Not at all, 4 is Extremely I have joint pains * Not at all 1 2 3 Extremely 4 1 is Not at all, 4 is Extremely Total Score Back Next About Menopause and Hormone Therapy How do you view menopause? * Positively. For example, menopause means no more periods and no more worry about contraception. Menopause marks a new life phase. Negatively. For example, menopause means a loss of fertility and loss of youth. Other What concerns you about menopause? * What are your current views regarding hormone therapy for menopause? * Positive. Hormone therapy is appropriate for some women. Negatively. I don’t support the use of hormone therapy. What concerns you most about hormone therapy for menopause? * How would you rate your knowledge about menopause? * Very good Fair Moderately good Little knowledge How do you get your information about menopause? (Mark all that apply.) * Books Internet Magazines Friends TV Healthcare Providers Back Next You will receive your total symptom score by email after you complete this questionnaire. We value your privacy. Your personal information will not be shared or sold to any individual or company. However, your responses may be used as a survey result to discuss common symptoms experienced by women. The questions have been adapted from the Menopause Health Questionnaire of the North American Menopause Society. Submit Should be Empty: