Menopause Treatment Questionnaire (short)

Patient Information

First Name:
Last Name:
Date of Birth:
Today's Date:
Age:

Your current hormone program:
Hormone Strength Base Dosage Location
Bi-Est
Progesterone
Testosterone
DHEA
Thyroid
Other
Other
Day of month you stop Bi-Est:
Day of month you begin Bi-Est:
Day of month you stop progesterone:
Day of month you begin progesterone:
Day of month you stop DHEA:
Day of month you begin DHEA:
Day of month you stop testosterone:
Day of month you begin testosterone:

Symptoms
Hot flashes:
Warm rushes:
Night sweats:
Kicking covers off at night:
Sleep disturbance:
Awaken with racing mind:
Vaginal dryness:
Use of lubrication during intercourse:
Pain during intercourse:
Vaginal atrophy:
Breast tenderness:
Nipple tenderness:
Breast fullness:
Breast pain:
Weight gain:
Times/night up to urinate:
Pubic hair loss:
Lose urine on cough:
Difficulty getting up from a chair:
Other (please specify):
General health assessment:
Energy level:
Sleep:
Memory:
Mood:
Libido: