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Online Health Assessment







Which of the following symptoms apply to you currently (in the last 2 weeks)? Please select the appropriate rating (None-Very Severe), using the drop down arrow for each symptom. For symptoms that do not currently apply or no longer apply, mark "none".

Hot Flashes

Sweating (night sweats or increase episodes of sweating)

Sleep problems (difficulty falling asleep, sleeping through the neight or waking up too early)

Depressive mood (feeling down, sad, on the verge of tears, lack of drive)

Irritability (mood swings, feeling aggressive, angers easily)

Anxiety (inner restlessness, feeling panicky, feeling nervous, inner tension)

Physical exhaustion (general decreas in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation)

Sexual Problems (change in sexual desire, sexual activity, orgasm and/or satisfaction)

Bladder problems (difficulty in urinating, increased need to urinate, incontinence)

Vaginal symptoms

Erectile changes (weaker erections, loos of morning erections)

Infrequent or absent ejaculations

Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)

Difficulties with memory

Problems with thinking, concentrating or reasoning

Difficulty learning new things

Trouble thinking of the right word to describe persons, places or things when speaking

Increase in frequency of instensity of headaches or migraines

Hair loss, thinning, or change in texture

Feel cold all the time or have cold hands or feet

Weight gain or difficulty losing weight despite diet and exercise

Dry or wrinkled skin

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