Female Checklist Date Name Phone Number Email Address Depressive Mood Depressive Mood Never Mild Moderate Severe Fatigue Fatigue Never Mild Moderate Severe Memory Loss Memory Loss Never Mild Moderate Severe Mental Confusion Mental Confusion Never Mild Moderate Severe Decreased Sex Drive/Libido Decreased Sex Drive/Libido Never Mild Moderate Severe Sleep Problems Sleep Problems Never Mild Moderate Severe Tension Tension Never Mild Moderate Severe Migraines/Headaches Migraines/Headaches Never Mild Moderate Severe Difficult To Climax Difficult To Climax Never Mild Moderate Severe Bloating Bloating Never Mild Moderate Severe Weight Gain Weight Gain Never Mild Moderate Severe Breast Tenderness Breast Tenderness Never Mild Moderate Severe Vaginal Dryness Vaginal Dryness Never Mild Moderate Severe Hot Flashes Hot Flashes Never Mild Moderate Severe Night Sweats Night Sweats Never Mild Moderate Severe Dry and Wrikled Skin Dry and Wrikled Skin Never Mild Moderate Severe Hair falling out Hair falling out Never Mild Moderate Severe Swelling all over the body Swelling all over the body Never Mild Moderate Severe Cold all the time Cold all the time Never Mild Moderate Severe Joint Pain Joint Pain Never Mild Moderate Severe 10 + 9 = Submit