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Menopause Assessment
Developed by the Berlin Center for Epidemiology and Health Research.
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HIPAA
Compliance
1
Hot Flashes, Sweating
*
This field is required.
(episodes of sweating)
None
Mild
Moderate
Severe
Extremely Severe
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2
Heart Discomfort
*
This field is required.
(unusual awareness of heartbeat, heart skipping, heart racing, tightness)
None
Mild
Moderate
Severe
Extremely Severe
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3
Sleep Problems
*
This field is required.
(difficulty falling asleep, difficulty in sleeping through, waking up early)
None
Mild
Moderate
Severe
Extremely Severe
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4
Depressive Mood
*
This field is required.
(feeling down, sad, on the verge of tears, lack of drive, mood swings)
None
Mild
Moderate
Severe
Extremely Severe
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5
Irritability
*
This field is required.
(feeling nervous, inner tension, feeling aggressive)
None
Mild
Moderate
Severe
Extremely Severe
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6
Anxiety
*
This field is required.
(inner restlessness, feeling panicky)
None
Mild
Moderate
Severe
Extremely Severe
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7
Physical and Mental Exhaustion
*
This field is required.
(general decrease in performance, impaired memory, decrease in concentration, forgetfulness)
None
Mild
Moderate
Severe
Extremely Severe
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8
Sexual Problems
*
This field is required.
(change in sexual desire, in sexual activity, in satisfaction)
None
Mild
Moderate
Severe
Extremely Severe
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9
Bladder Problems
*
This field is required.
(difficulty urinating, increased need to urinate, bladder incontinence)
None
Mild
Moderate
Severe
Extremely Severe
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10
Dryness of Vagina
*
This field is required.
(sensation of dryness or burning in the vagina, difficulty with sexual intercourse)
None
Mild
Moderate
Severe
Extremely Severe
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11
Joint and Muscular Discomfort
*
This field is required.
(pain in the joints, rheumatoid complaints)
None
Mild
Moderate
Severe
Extremely Severe
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12
Where should we send the results?
*
This field is required.
Please enter your name and email so that we can email your results. We won't share your information with anyone. If you would like us to reach out, also enter your phone number.
First Name
Last Name
Please enter your email
Please enter your phone if you would like to be contacted
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13
How should we contact you in the future?
*
This field is required.
Please check all that apply.
Email
Phone call
Text
I do not wish to be contacted
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14
Reach Out?
YES
NO
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15
Total Score
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16
Total Level
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17
Total Summary
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Small
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quote
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18
Psychological Score
depressed, irritable, anxious, exhausted
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19
Psychological Level
depressed, irritable, anxious, exhausted
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20
Psychological Summary
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21
Somatic Score
sweating/flush, cardiac complaints, sleeping disorders, joint and muscle complaints
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22
Somatic Level
sweating/flush, cardiac complaints, sleeping disorders, joint and muscle complaints
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23
Somatic Summary
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24
Urogenital Score
sexual problems, urinary complaints, vaginal dryness
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25
Urogenital Level
sexual problems, urinary complaints, vaginal dryness
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26
Urogenital Summary
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Ok
quote
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Ok
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