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Menopause Assessment Form
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Menopause Assessment Form
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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.
Submit
Home
Services
Health Clinic
Doctor Mentorship Programme
Life Coaching Service
Financial Coaching Service
Booking
Questionnaires
SF-36 Health Survey
Comprehensive Health History Form
PHQ-9 Depression Questionnaire
Perceived Stress Scale (PSS)
International Physical Activity Questionnaire (IPAQ)
PCL-5 (PTSD Checklist)
Food Frequency Questionnaire (FFQ)
Diabetes Distress Scale (DDS)
Simplified FRAX Calculator
Relationship Assessment Scale (RAS)
Chronic Pain Assessment Form
Child Behaviour Checklist (CBCL)
Conflict Resolution Style Questionnaire
Financial Well-Being Scale
Budget Assessment Worksheet
Hot Flushes Rating Questions
Menopause Assessment Form
Pittsburgh Sleep Quality Index (PSQI)
GAD-7 (Generalized Anxiety Disorder-7)
WHO-5 Well-Being Index
WHO Medical Eligibility Tool for Contraceptive Methods
Reproductive Life Planning Tool
International Physical Activity Questionnaire (IPAQ) – Short Form
Values and Priorities Inventory
Cognitive Failures Questionnaire (CFQ)
Everyday Memory Questionnaire (EMQ)
About Us
FAQs
My Account
Contact Us
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