Female Hormone Assessment (Prospects)

Symptoms in last 2 weeks

	None	Mild	Moderate	Severe	Very Severe
Hot flashes
Sleep problems (difficulty falling asleep, sleeping through the night, or waking to early)
Sweating (night sweats or increased episodes of sweating)
Depressive mood (feeling down, sad, on the verge of tears, 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 desire, sexual activity, orgasm and/or satisfaction)
Bladder problems ( difficulty urinating, increased need, incontinence)
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 or migraines
Hair loss, thinning or change in texture of hair
Feels cold all of the time or have cold hands or feet
Weight gain or difficulty losing weight despite diet and exercise
Dry or wrinkled skin

SUM

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