Client Symptoms

Patient First Name

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Patient Last Name

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1. Hot flushes, sweating (episodes of sweating)

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2. Heart discomfort (unusual awareness of heart beat, heart skipping, heart racing, tightness)

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3. Sleep problems (difficulty in falling asleep, difficulty in sleeping through, waking up early)

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

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5. Irritability (feeling nervous, inner tension, feeling aggressive)

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6. Anxiety (inner restlessness, feeling panicky)

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7. Physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness)

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8. Sexual problems (change in sexual desire, in sexual activity and satisfaction)

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

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10. Dryness of vagina (sensation of dryness or burning in the vagina, difficulty with sexual intercourse)

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11. Joint and muscular discomfort (pain in the joints, rheumatoid complaints)

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