My worst symptoms:
Night Sweats / Hot Flashes
Moodiness     
Emotional Instability
Chest Pains / Shortness of Breath
Memory Loss   
Panic Attacks
Changes in Periods           
Fibroids / Cramps
Headaches / Migraines
Facial Hair
Other 
        Brief Explanation (optional)

My moodiness was (is) mainly being: (choose all that apply)
Tearful         Cranky       Down-right Mean        
A combination of  moods        Other

Have you had these operations? (choose all that apply)
Hysterectomy (uterus removal)
Oophorectomy (ovary removal)
      One Ovary         Both Ovaries
Both operations at the same time
Neither operation

Was your menopause:
Natural and age-related
Not age-related, but due to: (choose all that apply)
      Surgery            Disease/Injury
      Premature Ovarian Failure
      Chemotherapy/Radiation/Medication

For age-related menopause:
Age you first noticed perimenopausal symptoms (period changes, hot flashes).
Age you went one full year without a period (official menopause).               Not there yet

I learn about menopause from: (choose all that apply)
Magazines               TV/Radio              Newspapers
Friends/family          My doctor            Other
I do my own research to learn about menopause.
I really don't know much about menopause.

My family and I: (choose all that apply)
My family has been supportive.
My menopause is driving my family crazy.
I've explained my menopause to my family.
My family is clueless about my Change of Life.
It was ok with me that I was entering menopause.
I was in denial for a while.

Do you exercise (any form): (choose all that apply)
Four to seven days a week.
One to three days a week.
Rarely exercise.
I fully understand the exercise/estrogen connection.
I don't understand the exercise/estrogen connection.

Are you currently using prescription Hormone Replacement Therapy (HRT)?
(choose all that apply)
Yes, estrogen only.
Yes, estrogen and progesterone.
Yes, progesterone only.
Yes, estrogen & other hormones.
Yes, but I'm thinking of getting off.
No. I have never taken prescription HRT.
No. I did take it but do not now.

Do you currently use herbal hormone products? (Non-prescription) (choose all that apply)
Yes, herbal estrogens (phyto-estrogens).
             Soy    Black Cohosh     Flaxseed      Other
Yes, herbal progesterone (phyto-progesterone).
No. I have never used herbal hormones.
I have used them but don't now.
After using them, I think they provide symptom relief.
After using them, I don't think they provide symptom relief.

I take hormone supplementation (prescription or non-prescription): (choose all that apply)
To prevent:
             Osteoporosis      Heart problems       Cancer
For hot flashes / night sweats.
Because my doctor told me to.
To regulate my periods.
Other.
Not applicable.

Are you "afraid" of HRT? (choose all that apply)
Yes   
No     
Kind of concerned
Don't know
It doesn't matter because I'm going to use them anyway.

Your Age        Today's Month / Year  JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC 2008 2009 2010

Your State or Country Please Choose State or Country AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WADC WI WV WY Australia Bermuda Canada France Germany Guam Malaysia New Zealand Puerto Rico South Africa United Kingdom OTHER
          If other, where are you?