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Name
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First
Last
Date of Birth
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Phone
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1. Are you still getting your periods? If so, have they been getting shorter or more unpredictable?
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Yes
No
2. Do you get hot flashes during the day or wake up at night drenched in sweat?
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Yes
No
3. Have friends or family mentioned that you’ve been more irritable lately?
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Yes
No
4. Has your interest in sex decreased, or do you experience dryness or discomfort during intercourse?
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Yes
No
5. Are you feeling more tired or less energetic than usual?
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Yes
No
6. Have you noticed changes in your body shape, or are you finding it harder to manage your weight?
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Yes
No
7. Are you dealing with hair thinning or changes in your skin like dryness?
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Yes
No
8. Do you have trouble falling asleep or staying asleep through the night?
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Yes
No
9. Have you noticed that you’re forgetting things more often?
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Yes
No
10. Are you having more frequent headaches or migraines?
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Yes
No
11. Do you feel the need to pee more often or urgently, or have you experienced any bladder leaks?
*
Yes
No
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