Please complete and submit the form below to view your results. Are you experiencing... 1 Heart beating quickly, strongly or skipping Mild Moderate Severe   Is this a problem? Yes No 2 Hot flashes during day or night Mild Moderate Severe   Is this a problem? Yes No 3 Difficulty in sleeping Mild Moderate Severe   Is this a problem? Yes No 4 Feeling depressed, sad, or having mood swings Mild Moderate Severe   Is this a problem? Yes No 5 Feeling panicky, restless, or worrying needlessly Mild Moderate Severe   Is this a problem? Yes No 6 Difficulty in concentrating or decrease in memory Mild Moderate Severe   Is this a problem? Yes No 7 Feeling tired or lacking in energy Mild Moderate Severe   Is this a problem? Yes No 8 Vaginal dryness Mild Moderate Severe   Is this a problem? Yes No 9 Difficulty with sexual intercourse Mild Moderate Severe   Is this a problem? Yes No 10 Loss of interest in sex Mild Moderate Severe   Is this a problem? Yes No 11 Change in menstrual patterns Mild Moderate Severe   Is this a problem? Yes No 12 Muscle and joint pains Mild Moderate Severe   Is this a problem? Yes No 13 Urine leakage/frequency Mild Moderate Severe   Is this a problem? Yes No   username password

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