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