Instructions:
For each symptom you’ve experienced in the past 3–6 months, rate its severity using the scale below.
Severity Scale:
0 = Not present
1 = Very mild (noticeable, not disruptive)
2 = Mild (occasionally disruptive)
3 = Moderate (regularly disruptive)
4 = Severe (significantly affects daily life)
Menstrual Changes
- Irregular periods (shorter/longer cycles) ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Skipped periods ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Heavier bleeding ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Lighter bleeding ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Spotting between periods ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Increased PMS symptoms ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
Vasomotor (Temperature-Related) Symptoms
- Hot flashes ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Night sweats ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Sudden flushing or warmth ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Sleep disruption from temperature changes ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
Sleep & Energy
- Difficulty falling asleep ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Nighttime awakenings ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Early morning waking ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Non-restorative sleep ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Daytime fatigue ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
Mood & Emotional Changes
- Mood swings ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Irritability ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Anxiety or nervousness ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Low mood or sadness ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Reduced stress tolerance ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
Cognitive Changes
- Brain fog ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Difficulty concentrating ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Forgetfulness ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Word-finding difficulty ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
Physical Body Changes
- Weight gain (especially midsection) ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Joint or muscle aches ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Headaches or migraines ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Breast tenderness ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Skin dryness or changes ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Hair thinning or loss ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
Sexual & Vaginal Health
- Vaginal dryness ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Pain or discomfort during sex ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Lower libido ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Vaginal irritation or burning ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Urinary urgency or frequency ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
Heart & Autonomic Symptoms
- Heart palpitations ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Racing heart without clear cause ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Lightheadedness ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
Overall Well-Being
- Reduced resilience ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Feeling unlike yourself ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Decreased motivation ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
- Sense that “something has shifted” ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
Scoring & Reflection
- Here’s a checklist suitable for clinical use, self-tracking, or bringing to a medical appointment.
- Which symptoms score 3 or 4?
- Which category has the highest total severity?
- Which symptoms most interfere with quality of life?
- Are symptoms cyclical, worsening, or constant?
Clinical Note
High-severity scores, especially for mood changes, sleep disruption, heavy bleeding, or palpitations are important to discuss with a healthcare provider. This checklist is a conversation tool, not a diagnosis.
