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Menopause Assessment Form
Book an Appointment
Instructions:
Please rate how much each symptom has troubled you over the past week. Use the following scale:
0 = Not at all
1 = A little
2 = Moderately
3 = Quite a bit
4 = Extremely
1. Physical Symptoms
1. Hot flashes or sweating episodes, especially at night:
0
1
2
3
4
2. Difficulty sleeping or restless sleep:
0
1
2
3
4
3. Muscle or joint pains:
0
1
2
3
4
4. Tiredness or lack of energy:
0
1
2
3
4
5. Headaches or feeling dizzy:
0
1
2
3
4
2. Psychological Symptoms
6. Feeling tense, anxious, or worried:
0
1
2
3
4
7. Irritability or mood swings:
0
1
2
3
4
8. Feeling depressed or sad:
0
1
2
3
4
9. Difficulty concentrating or forgetfulness:
0
1
2
3
4
10. Feeling less confident or unsure about yourself:
0
1
2
3
4
3. Sexual and Social Well-being
11. Decrease in sexual desire or enjoyment
0
1
2
3
4
12. Vaginal dryness or discomfort during intimacy:
0
1
2
3
4
13. Feeling disconnected from family or social life:
0
1
2
3
4
Total Score
Interpretation of Results:
0–10: Symptoms are mild. Lifestyle adjustments, such as regular exercise and a balanced diet, may help manage symptoms.
11–20: Moderate symptoms. You may benefit from consulting a healthcare provider to explore treatment options
21+: Severe symptoms. A medical evaluation is strongly recommended to develop a tailored management plan.
What’s Next?
To address your symptoms and receive personalized advice, book an appointment with the Zan Center for menopause care today.
Click here to book your consultation
Disclaimer: This assessment is for informational purposes only. Please consult with a qualified healthcare professional for an accurate diagnosis and treatment plan.
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