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20

Do you get tired quickly?

Yes No

19

Do you feel stiffness or pain in your lower back after a night's rest?

Yes No

18

Do you feel sharp pain in your knees?

Yes No

17

Do you get up more than twice a night to go to the bathroom?

Yes No

16

Do you suffer from insomnia?

Yes No

15

Do your hands and feet often get cold?

Yes No

14

Have you noticed a decrease in sexual function?

Yes No

13

Has your menstrual cycle schedule been disrupted?

Yes No Does not apply to me (no menstrual cycle)

12

Do you experience frequent dizziness and headaches?

Yes No

11

Have you experienced increased sweating?

Yes No

10

Have you noticed increased eye fatigue or tearing?

Yes No

9

Are you prone to frequent colds?

Yes No

8

Do you experience ringing in your ears?

Yes No

7

Do you have dry hair, excessive hair loss, or early graying?

Yes No

6

Do you feel a bitter taste in your mouth and notice redness of the tongue?

Yes No

5

Do you feel pain in the area of the solar plexus?

Yes No

4

Is your blood pressure stable?

Yes, stable No, unstable (often increases or decreases)

3

Do you often experience unexplained fear and anxiety?

Yes No

2

Have you noticed forgetfulness or distractibility in yourself?

Yes No

1

Are you losing weight even if you are not on a diet?

Yes No