EvexiPEL Symptom Screen – Female
Name
Name
First
Last
Hot Flashes, Sweating (Episodes of Sweating)
Heart Discomfort (unusual awareness of heart beat, heart skipping, heart racing, tightness)
Sleep Problems (difficulty in falling asleep, sleeping through the night, waking early)
Depressive Mood (feeling down, sad, on the verge of tears, lack of drive, mood swings)
Irritability (feeling nervous, inner tension, feeling aggressive)
Anxiety (inner restlessness, feeling panicky)
Physical and Mental Exhaustion (decreased performance, concentration, memory, forgetfulness)
Sexual Problems (change in sexual desire, in sexual activity, and satisfaction)
Bladder Problems (difficulty urinating, increased urination, bladder incontinence)
Dryness of Vagina (sensation of dryness/burning, difficulty with sexual intercourse)
Joint and Muscular Discomfort (pain in the joints, rheumatoid complaints)
Do you have cold hands and feet?
Do you have daily bowel movements?
Do you have gas, bloating or abdominal pain after eating?
Please select your weekly activity level. (Activity that raises heart rate & breathing)