When answering these questions, keep the following rating scale in mind:

• Mild:  A minor issue- it happens occasionally, but it doesn’t affect me much.
• Moderate:  A real problem, but I push myself through it.
• Severe:  I can barely function or deal with it.

I have hot flashes or night sweats
Mild
Moderate
Severe

I suffer from PMS (I have cramps, nausea, breast tenderness, and/or irritability).
Mild
Moderate
Severe

I have difficulty falling asleep.
Mild
Moderate
Severe

I have difficulty staying asleep.
Mild
Moderate
Severe

I feel very tired, especially in the afternoon.
Mild
Moderate
Severe

I am fatigued or have a loss of energy.
Mild
Moderate
Severe

I am anxious, have anxiety attacks, or have heart palpitations.
Mild
Moderate
Severe

I am forgetful, foggy-headed or absentminded.
Mild
Moderate
Severe

I sometimes feel overwhelmed, confused, or just not myself.
Mild
Moderate
Severe

I feel stiff or achy in my joints, especially in the morning.
Mild
Moderate
Severe

I feel that I've gained weight faster than usual, especially around the middle.
Mild
Moderate
Severe

My interest in sex is not what it used to be.
Mild
Moderate
Severe

I suffer from vaginal dryness.
Mild
Moderate
Severe