Have you experienced any of the following symptoms recently? Please indicate the severity of each symptom below.

0 = Absent (symptom not present)
1 = Mild (present but not distressing)
2 = Moderate (distressing, but not interfering with daily life)
3 = Severe (very distressing, interferes with daily life)

	Absent	Mild	Mod.	Severe
	0	1	2	3
Hot flushes OR Night Sweats
Light-headed Feelings/Dizziness
Headaches
Sleep Disturbances OR Sleeplessness
Unusual Tiredness/Fatigue
Irritability
Depression
Unloved Feelings
Anxiety/Nervous/Irritable
Mood Swings/Mood Changes
Backache
Joint Pains
Muscle Pains
New Facial Hair
Dry Skin/Dry Hair
Crawling Feeling Under Skin
Frequent UTI/Urinary frequency/Incontinence
Dry Vagina
Uncomfortable intercourse/Painful Sex
Loss of Sexual Feeling/Desire
Loss of Arousability & Capacity for Orgasm
Loss of sexual sensitivity in: -Clitoris
Loss of sexual sensitivity in: -Nipples
Loss of Muscle /Thining of Skin
Any Recent Change in Body Hair Patterns
Foggy Thinking or Memory Lapses
Palpitations or Shortness of Breath
Discharge or Leaking from Nipples
Breast Swelling/Tenderness
Pelvic pain, Pressure, Fullness, Bloating
Heavy/Irregular/Abnormal Bleeding
Shortened Cycle/Menstrual Cramping or Pain
Nausea/Upset Stomach/Diarrhea/Painful B.M.
Cravings/Sweets/Salts/Chocolate
Increased appetite/Weight Gain
Allergies/Cold Body/Aches/Pains/Arthritis
Crying Easily
Swelling of Hands/Ankles
Yeast or Candida Infection
Acne OR Oily Skin
Tightness in neck/shoulders
Recent Visual Change or Decreased Vision
	0	1	2	3
	Absent	Mild	Mod.	Severe

Please use the box below to elaborate on any symptoms you experience; also, unlisted symptoms can be described in this box. If you have a change in symptoms, please report them via this form. You should report symptoms at least once monthly, preferrably about day 21-23 of your cycle. If not cycling, then monthly at least 7 days before you are out of your prescription. Your prescription reorder can be listed in this box also. When finished, be sure to hit "submit."