Menopause Symptom Form - The Brimington Surgery

Heart beating quickly or strongly *

Not at all - 0

A little - 1

Quite a bit - 2

Extremely - 3

Feeling tense or nervous *

Not at all - 0

A little - 1

Quite a bit - 2

Extremely - 3

Difficulty in sleeping *

Not at all - 0

A little - 1

Quite a bit - 2

Extremely - 3

Excitable *

Not at all - 0

A little - 1

Quite a bit - 2

Extremely - 3

Attacks of anxiety, panic *

Not at all - 0

A little - 1

Quite a bit - 2

Extremely - 3

Difficulty in concentrating *

Not at all - 0

A little - 1

Quite a bit - 2

Extremely - 3

Feeling tired or lacking in energy *

Not at all - 0

A little - 1

Quite a bit - 2

Extremely - 3

Loss of interest in most things *

Not at all - 0

A little - 1

Quite a bit - 2

Extremely - 3

Feeling unhappy or depressed *

Not at all - 0

A little - 1

Quite a bit - 2

Extremely - 3

Crying spells *

Not at all - 0

A little - 1

Quite a bit - 2

Extremely - 3

Irritability *

Not at all - 0

A little - 1

Quite a bit - 2

Extremely - 3

Feeling dizzy or faint *

Not at all - 0

A little - 1

Quite a bit - 2

Extremely - 3

Pressure or tightness in head *

Not at all - 0

A little - 1

Quite a bit - 2

Extremely - 3

Parts of body feel numb *

Not at all - 0

A little - 1

Quite a bit - 2

Extremely - 3

Headaches *

Not at all - 0

A little - 1

Quite a bit - 2

Extremely - 3

Muscle and joint pains *

Not at all - 0

A little - 1

Quite a bit - 2

Extremely - 3

Loss of feeling in hands or feet *

Not at all - 0

A little - 1

Quite a bit - 2

Extremely - 3

Breathing difficulties *

Not at all - 0

A little - 1

Quite a bit - 2

Extremely - 3

Hot flushes *

Not at all - 0

A little - 1

Quite a bit - 2

Extremely - 3

Sweating at night *

Not at all - 0

A little - 1

Quite a bit - 2

Extremely - 3

Loss of interest in sex *

Not at all - 0

A little - 1

Quite a bit - 2

Extremely - 3

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form.

Menopause Symptoms - Greene Scale

Further Information

Cookies on the The Brimington Surgery website

Menopause Symptoms - Greene Scale

Further Information