Female Health Assessment Form

Please complete the form below and identify the symptoms that apply to you (within the past 2 weeks.) Please mark the appropriate checkbox for each symptom. For symptoms that do not currently apply, mark “never.”

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Hot Flashes

Sweating: Night Sweats or Excessive Sweating

Sleep Problems (Difficulty Falling Asleep, SleepingThrough the Night or Waking Up Too Early)

Depressed Mood (Feeling Down, Sad, Lack of Drive)

Irritability (Mood Swings, Feeling Aggressive, Angers Easily

Anxiety (Inner Restlessness, Feeling Panicky, Feeling Nervous, Inner Tension)

Physical Exhaustion (General Decrease in Muscle Strength or Endurance, Decrease in Work Performance, Fatigue, Lack of Energy, Stamina or Motivation)

Sexual Problems (Change in Sexual Desire or in Sexual Performance)

Bladder Problems (Difficulty Urinating, Increased Need to Urinate)

Vaginal Symptoms (Sensation of Dryness or Burning in Vagina, Difficulty with Sexual Intercourse)

Joint and Muscular Symptoms (Joint Pain or Swelling, Muscle Weakness, Poor Recovery After Exercise)

Difficulties With Memory

Problems With Thinking, Concentrating or Reasoning

Difficulty Learning New Things

Trouble Thinking of the Right Word to Describe Persons, Places or Things When Speaking

Increase in Frequency or Intensity of Headaches / Migraines

Rapid Hair Loss or Thinning Hair

Feel Cold All the Time or Have Cold Hands or Feet

Weight Gain, Increased Belly Fat, or Difficulty Losing Weight Despite Diet and Exercise

Dry or Wrinkled Skin