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Menopause Specific Quality of Life Questionnaire

For each item listed below, indicate by checking "YES" or "NO" whether you have experienced the problem in the PAST WEEK. If you have, rate the degree to which you have been bothered by the problem.

 
1. HOT FLUSHES OR FLASHES
 
Yes No
0 1 2 3 4 5 6
2. NIGHT SWEATS
 
Yes No
0 1 2 3 4 5 6
3. SWEATING
 
Yes No
0 1 2 3 4 5 6
4. DISSATISFACTION WITH MY PERSONAL LIFE
 
Yes No
0 1 2 3 4 5 6
5. FEELING ANXIOUS OR NERVOUS
 
Yes No
0 1 2 3 4 5 6
6. POOR MEMORY
 
Yes No
0 1 2 3 4 5 6
7. ACCOMPLISHING LESS THAN USED TO
 
Yes No
0 1 2 3 4 5 6
8. FEELING DEPRESSED, DOWN OR BLUE
 
Yes No
0 1 2 3 4 5 6
9. BEING IMPATIENT WITH OTHER PEOPLE
 
Yes No
0 1 2 3 4 5 6
10. FEELINGS OF WANTINGTO BE ALONE
 
Yes No
0 1 2 3 4 5 6
11. FLATULENCE (WIND) OR GAS PAINS
 
Yes No
0 1 2 3 4 5 6
12. ACHING IN MUSCLES AND JOINTS
 
Yes No
0 1 2 3 4 5 6
13. FEELING TIRED OR WORN OUT
 
Yes No
0 1 2 3 4 5 6
14. DIFFICULTY SLEEPING
 
Yes No
0 1 2 3 4 5 6
15. ACHES IN BACK OF NECK OR HEAD
 
Yes No
0 1 2 3 4 5 6
16. DECREASE IN PHYSICAL STRENGTH
 
Yes No
0 1 2 3 4 5 6
17. DECREASE IN STAMINA
 
Yes No
0 1 2 3 4 5 6
18. LACK OF ENERGY
 
Yes No
0 1 2 3 4 5 6
19. DRY SKIN
 
Yes No
0 1 2 3 4 5 6
20. WEIGHT GAIN
 
Yes No
0 1 2 3 4 5 6
21. INCREASED FACIAL HAIR
 
Yes No
0 1 2 3 4 5 6
22. CHANGE IN APPEAR- ANCE, TEXTURE OR TONE OF MY SKIN
 
Yes No
0 1 2 3 4 5 6
23. FEELING BLOATED
 
Yes No
0 1 2 3 4 5 6
24. LOW BACKACHE
 
Yes No
0 1 2 3 4 5 6
25. FREQUENT URINATION
 
Yes No
0 1 2 3 4 5 6
26. INVOLUNTARY URINATION WHEN LAUGHING OR COUGHING
 
Yes No
0 1 2 3 4 5 6
27. DECREASE IN MY SEXUAL DESIRE
 
Yes No
0 1 2 3 4 5 6
28. VAGINAL DRYNESS
 
Yes No
0 1 2 3 4 5 6
29. AVOIDING INTIMACY
 
Yes No
0 1 2 3 4 5 6
30. BREAST PAIN OR TENDERNESS
 
Yes No
0 1 2 3 4 5 6
31. VAGINAL BLEEDING OR SPOTTING
 
Yes No
0 1 2 3 4 5 6
32. LEG PAINS OR CRAMPS
 
Yes No
0 1 2 3 4 5 6

We recommend saving the results and re-taking this survey every 30 days. This will allow you to compare your scores over time to determine objectively how Estrofil is impacting your quality of life. Some women will see results in weeks while others may not begin to see results for more then 60 days.

 

Rate your Menopause Quality of Life

Before starting Estrofil, or any other regimen intended to reduce the effects of menopause, be sure to score your quality of life using a standard research questionnaire.
Download Questionaire

Did you Know?

Being fit not only decreases the long-term risks of cardiovascular disease, osteoporosis, and obesity, it also plays a role in how symptoms of hormonal change affect you.
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These statements have not been evaluated by the FDA.
This product is not intended to diagnose, treat, cure, or
prevent any disease.

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