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For each of the following items, indicate how much the problem has bothered you in the past month.  If you haven’t experienced the problem, please indicate so.

1.Hot flushes or flashes
2.Night sweats
4.Being dissatisfied with my personal life
5.Feeling anxious or nervous
6.Experiencing poor memory
7.Accomplishing less than I used to
8.Feeling depressed, down or blue
9.Being impatient with other people
10.Feelings of wanting to be alone
11.Flatulence (wind) or gas pains
12.Involuntary urination when laughing or coughing
13.Change in your sexual desire
14.Vaginal dryness during intercourse
15.Avoiding intimacy
16.Decrease in physical strength
17.Decrease in stamina
18.Feeling a lack of energy
19.Drying skin
20.Weight gain
21.Increased facial hair
22.Changes in appearance, texture or tone of your skin
23.Feeling bloated
24.Low backache
25.Frequent urination
26.Involuntary urination when laughing or coughing
27.Change in your sexual desire
28.Vaginal dryness during intercourse
29.Avoiding intimacy

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