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Women's Health & Vitality Assessment
Women's Health Assessment
Which of the following symptoms apply to you currently (in the last 2 weeks)? Please make the appropriate selection for each symptom down below. For symptoms that do not currently apply or no longer apply, mark "none".
First Name *
Last Name *
Email *
Mobile Phone *
Symptoms
Hot Flashes *
Please select one
(0) - None
(1) - Mild
(2) - Moderate
(3) - Severe
(4) - Very Severe
Sweating (night sweats or excessive sweating) *
Please select one
(0) - None
(1) - Mild
(2) - Moderate
(3) - Severe
(4) - Very Severe
Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early) *
Please select one
(0) - None
(1) - Mild
(2) - Moderate
(3) - Severe
(4) - Very Severe
Depressive Mood (feeling down, sad, lacking drive) *
Please select one
(0) - None
(1) - Mild
(2) - Moderate
(3) - Severe
(4) - Very Severe
Irritability (mood swings, feeling aggressive, angers easily) *
Please select one
(0) - None
(1) - Mild
(2) - Moderate
(3) - Severe
(4) - Very Severe
Anxiety (inner restlessness, panicked, nervous, inner tension) *
Please select one
(0) - None
(1) - Mild
(2) - Moderate
(3) - Severe
(4) - Very Severe
Physical Exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation) *
Please select one
(0) - None
(1) - Mild
(2) - Moderate
(3) - Severe
(4) - Very Severe
Sexual Problems (change in sexual desire, sexual activity, orgasm and/or satisfaction) *
Please select one
(0) - None
(1) - Mild
(2) - Moderate
(3) - Severe
(4) - Very Severe
Bladder Problems (difficulty or increased need to urinate, incontinence)) *
Please select one
(0) - None
(1) - Mild
(2) - Moderate
(3) - Severe
(4) - Very Severe
Vaginal Symptoms (sensation of dryness or burning in vagina, difficulty with sexual intercourse) *
Please select one
(0) - None
(1) - Mild
(2) - Moderate
(3) - Severe
(4) - Very Severe
Joint & Muscle Symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise) *
Please select one
(0) - None
(1) - Mild
(2) - Moderate
(3) - Severe
(4) - Very Severe
Difficulties with Memory *
Please select one
(0) - None
(1) - Mild
(2) - Moderate
(3) - Severe
(4) - Very Severe
Problems with thinking, concentrating, or reasoning *
Please select one
(0) - None
(1) - Mild
(2) - Moderate
(3) - Severe
(4) - Very Severe
Difficulty learning new things *
Please select one
(0) - None
(1) - Mild
(2) - Moderate
(3) - Severe
(4) - Very Severe
Trouble thinking of right word to describe person/place/things when speaking *
Please select one
(0) - None
(1) - Mild
(2) - Moderate
(3) - Severe
(4) - Very Severe
Increase in frequency or intensity of headaches/migraines *
Please select one
(0) - None
(1) - Mild
(2) - Moderate
(3) - Severe
(4) - Very Severe
Hair loss, thinning or change in texture of hair *
Please select one
(0) - None
(1) - Mild
(2) - Moderate
(3) - Severe
(4) - Very Severe
Feel cold all the time or have cold hands or feet *
Please select one
(0) - None
(1) - Mild
(2) - Moderate
(3) - Severe
(4) - Very Severe
Weight gain or difficulty losing weight despite diet/exercise *
Please select one
(0) - None
(1) - Mild
(2) - Moderate
(3) - Severe
(4) - Very Severe
Dry or Wrinkled Skin *
Please select one
(0) - None
(1) - Mild
(2) - Moderate
(3) - Severe
(4) - Very Severe
NOTE:
Please add up your score and enter it below.
Total Score *
Severity Score: Mild 1-20 / Moderate: 21-40 / Severe: 41-60 / Very Severe: 61-80
Submit
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