Name
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ON a scale of 1 to 10, 1 being not bad and 10 being bad, how would you rate your sleep?
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ON a scale of 1 to 10, 1 being not so bad and 10 really bad, how would you rate your ability to fall asleep recently?
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On average how long does it take you to fall asleep?
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0 to 5 minutes
15 to 30 minutes
1 hour or more
2 hours
3 hours
4 hours
5 hours or more
Other
On Average how long does it take you to fall asleep: Other
ON a scale of 1 to 10, 1 being not so bad and 10 really bad, how would you rate your waking through the night?
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ON average how many times a night do you wake?
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5 or more
Other
On average how many times a night do you wake? Others:
On average how long are you awake?
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0 to 5 minutes
15 to 30 minutes
30 minutes to an hour
1 hours or more
2 hours
3 hours
4 hours
5 hours or more
Other
On average how many times a night do you wake? Others:
ON a scale of 1 to 10, 1 being not so bad and 10 really bad, how would you rate your hot flushes at night?
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ON a scale of 1 to 10, 1 being not so bad and 10 really bad, how would you rate your hot flushes during the day?
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ON a scale of 1 to 10, 1 being not so bad and 10 really bad, how would you rate your night sweats?
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ON a scale of 1 to 10, 1 being bad and 10 AWESOME, how would you rate your energy when you wake up?
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ON a scale of 1 to 10, 1 being bad and 10 AWESOME, how would you rate your energy throughout the day?
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ON a scale of 1 to 10, 1 being good and 10 VERY BAD, how would you rate your anxiety during the day?
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ON a scale of 1 to 10, 1 being good and 10 VERY BAD, how would you rate your anxiety during the night?
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On a scale of 1 to 10, with 1 being not at all and 10 being very angry, how angry are you feeling?
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On a scale of 1 to 10, with 1 being not at all and 10 being badly, how is menopause affecting your sex life and relationships?
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On a scale of 1 to 10, with 1 being not at all and 10 being badly, how is menopause affecting your ability to work or do your job?
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Is there anything you would like to share with us about how your menopause journey is affecting you?*
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