Date of Birth *

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DD

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Symptoms *

Please check all that apply, also bear in mind that some symptoms may have causes other than the menopause, so if you are concerned you should have them checked out.

Heart beating quickly or strongly

Feeling tense or nervous

Difficulty in sleeping

Memory problems

Attacks of anxiety, panic

Difficulty in concentrating

Feeling tired or lacking in energy

Loss of interest in most things

Feeling unhappy or depressed

Crying spells

Irritability

Feeling dizzy or faint

Pressure or tightness in head

Tinnitus (ringing or buzzing in the ears)

Headaches

Muscle and joint pains

Pins and needles in any part of the body

Breathing difficulties

Hot flushes

Sweating at night

Loss of interest in sex

Urinary symptoms

Symptoms due to vaginal dryness