AMS Checklist -BEFORE HRT Place an “X” for EACH symptom you are currently experiencing. Please mark only ONE box. For symptoms that do not apply, please mark NONE. 01. Hot flashes, sweating (episodes of sweating) None Mild Moderate Severe Extremely Severe 02. Heart discomfort (unusual awareness of heart beat, heart skipping, heart racing, tightness) None Mild Moderate Severe Extremely Severe 03. Sleep problems (difficulty in falling asleep, difficulty in sleeping through the night, waking up early) None Mild Moderate Severe Extremely Severe 04. Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings) None Mild Moderate Severe Extremely Severe 05. Irritability (feeling nervous, inner tension, feeling aggressive) None Mild Moderate Severe Extremely Severe 06. Anxiety (inner restlessness, feeling panicky) None Mild Moderate Severe Extremely Severe 07. Physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness) None Mild Moderate Severe Extremely Severe 08. Sexual problems (change in sexual desire, in sexual activity and satisfaction) None Mild Moderate Severe Extremely Severe 09. Bladder problems (difficulty in urinating, increased need to urinate, bladder incontinence) None Mild Moderate Severe Extremely Severe 10. Dryness of vagina (sensation of dryness or burning in the vagina, difficulty with sexual intercourse) None Mild Moderate Severe Extremely Severe 11. Joint and muscular discomfort (pain in the joints, rheumatoid complaints) None Mild Moderate Severe Extremely Severe Please share any additional comments about your symptoms you would like to address. Do you have cold hands and feet? Yes No Do you have daily bowel movements? Yes No Do you have gas, bloating or abdominal pain after eating? Yes No Please select your WEEKLY Activity Level based on this criteria Physical activity that accelerates heart rate / Breathlessness 0-1 day per week (Low) 2-3 days per week (Average) More than 3 days per week (High) Please list any prior hormone therapy? Thank you!