| Section B | |
| (1) Are you having more aches and pain? Are you starting to get arthritis? | Yes No |
| (2) Are you having more spotting or break-through bleeding? Have you been told you have Dysfunctional Uterine Bleeding? | Yes No |
| (3) Do you seem to be getting more inflammations and swellings? | Yes No |
| (4) Are your allergies or asthma getting worse, or are you developing new allergies or asthma? | Yes No |
| (5) Do you feel like you are having more twitches and spasms? | Yes No |
| (6) Are you experiencing times of mental fogginess, or trouble thinking clearly? | Yes No |
| (7) Are you having more mood swings? | Yes No |
| (8) Do you feel more fatigued? Are you more tired in the morning? | Yes No |
| (9) Are you more irritable? Do you have more nervous tension? | Yes No |
| (10) Are you experiencing more anxiety? Do you feel more anxious? | Yes No |
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Section C |
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(1) Do you feel less motivated in general? Do you feel less assertive? |
Yes No | |
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(2) Is your libido lessened? Are you having less sexual fantasies or less desire? Are you less likely to become sexually aroused? Are you less pleased with sex? |
Yes No | |
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(3) Are you feeling less composed and in control? |
Yes No | |
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(4) Are you less energetic? |
Yes No | |
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(5) Are you anemic, or think you are anemic? |
Yes No | |
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(6) Are you feeling more irritable? |
Yes No | |
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(7) Do you have less muscle strength? Do you feel weaker? |
Yes No | |
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(8) Are you having more trouble with mental skills requiring logic and problem solving? Are you having trouble focusing and maintaining your attention? |
Yes No | |
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(9) Is your memory weakening? Are you having more trouble remembering things and events? |
Yes No | |
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(10) Do you feel more depressed? Is your mood low, less confident? Are you feeling frightened or afraid? |
Yes No | |
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Section D |
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(1) Are you noticing more wrinkles around your mouth and eyes? Is the skin tone on you arms, legs, or hands poor? Has the skin lost its firmness or fullness? |
Yes No |
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(2) Do you feel more depressed? |
Yes No |
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(3) Do you feel more fatigue in general? |
Yes No |
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(4) Are you having more headaches? |
Yes No |
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(5) Are you over 45 years old? |
Yes No |
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Section E |
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(1) Does it seem as though your breast are shrinking and sagging? |
Yes No |
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(2) Are you experiencing more confusion? |
Yes No |
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(3) Are you experiencing more morning fatigue? |
Yes No |
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(4) Do you cry more easily, or more often? |
Yes No |
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(5) Are your hands or feet colder? |
Yes No |
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Section F |
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(1) Is your libido less than it used to be? |
Yes No |
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(2) Is your pubic hair thinning? |
Yes No |
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(3) Do you feel less motivated, less assertive, less confident? Have you lost your competitive edge? |
Yes No |
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(4) Are you gaining more body fat? Do you feel less lean? |
Yes No |
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(5) Are you having more lower back pain or hip pain? Do you feel more joint pain? Are you having more headaches? |
Yes No |
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Section G |
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(1) Are you developing more facial hair (hirsutism)? |
Yes No |
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(2) Is your voice changing and becoming deeper or more masculine? |
Yes No |
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(3) Are you having trouble tolerating sugars and carbohydrates? |
Yes No |
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(4) Are you developing or having increased acne? |
Yes No |
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(5) Do you feel more hostile, angry, agitated or aggressive? |
Yes No |
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Your have completed the questionnaire. |
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