This subjective questionnaire will give your health care practitioner a quick summary of symptoms or signs that may be related to common women's health issues. It is not a substitute for professional medical advice from your health care provider. Do you have a lack of energy?*YesNoDo you feel stressed? *YesNoDo you experience restless sleep or insomnia?*YesNoDo you feel sad and/or grumpy?*YesNoDo you have mood swings?*YesNoDo you have difficulty concentrating?*YesNoAre you forgetful?*YesNoDo you have premenstrual symptoms? *YesNoDo you have pre- or postmenopausal hot flashes and/or night sweats?*YesNoHave you noticed a decrease in your sex drive?*YesNoHave you recently gained weight?*YesNoAre you overweight?*YesNoHave you lost height?*YesNoName* First Last Phone*Email*