Menopause Symptom Checklist

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Personal Details

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Please note that you will need to remember this as it will be used to verify your identity at the start of the clinic

Menopause Symptoms

This can be used to monitor symptoms and is worth doing regularly to assess how symptoms change with time or with treatment

Please indicate the extent to which you are bothered at the moment by any of these symptoms

Heart beating quickly or strongly: *

Feeling tense or nervous: *

Difficulty sleeping: *

Memory problems: *

Attacks of panic: *

Difficulty concentrating: *

Feeling tired or lacking energy: *

Loss of interest in most things: *

Feeling unhappy or depressed: *

Crying spells: *

Irritability: *

Feeling dizzy or faint: *

Pressure or tightness in head or body: *

Tinnitus (ringing or buzzing in the ear): *

Headaches: *

Muscle and joint pains: *

Pins and needles in any part of the body: *

Breathing difficulties: *

Hot flushes: *

Sweating at night: *

Loss of interest in sex: *

Urinary symptoms: *

Symptoms due to vaginal dryness: *

My total score:

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Menopause Symptom Checklist

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