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MENSI Questionnaire

In the last month did you experience... Was it a problem?
1. Hot or warm flashes? yes no
2. Palpitations? yes no
3. Headaches? yes no
4. Sleep disturbance? yes no
5. Chest pressure or pain? yes no
6. Shortness of breath? yes no
7. Numbness? yes no
8. Weakness or fatigue? yes no
9. Pain in bone joints? yes no
10. Memory loss? yes no
11. Anxiety? yes no
12. Depression? yes no
13. Fear of going out of the home? yes no
14. Loss of urinary control? yes no
15. Vaginal dryness? yes no
16. Loss of sexual desire? yes no
17. Pain with intercourse? yes no
18. Disrupted function: Home? yes no
19. Disrupted function: Work? yes no



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