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The Praxis

Onboarding Symptom Questionnaire

Take a few quiet minutes with yourself. There are no right or wrong answers — only where you are today.

Personal details

Name
Age
Height
Weight
Last gynecologist visit
Waist / hip circumference / ratio (optional)

Part 1: Symptoms

Which of the following symptoms currently apply to you?
0
No symptom
1
2
3
Very strong symptom
Hot flashes
Night sweats / sweating
Sleep problems
Mood swings
Irritability
Anxiety
Exhaustion / fatigue
Brain fog
Reduced libido
Depressive moods
Heart palpitations
Itching
Joint & muscle pain
Weight gain (uncontrolled)
Skin changes (e.g. dryness, elasticity)
Headaches
Bloating
Thinning hair
Dry eyes
Dry mouth
Sore breasts
Tearfulness / thin-skinnedness
Panic attacks
Brittle nails
Urinary tract infections
Urinary incontinence
Restless legs
Vaginal dryness / vulvovaginal atrophy
Vaginal discomfort (burning, itching, yeast infections, etc.)
Increased vaginal discharge
Painful sex
Low self-confidence
Inability to complete tasks
Anger and rage

Please tick the box that fits each symptom. If a symptom does not apply, choose “0 – no symptom”.

Which symptom bothers you the most?

Part 2: Cycle & Medical History

At what age did you have your first period?
What was your cycle like in the past? (regular/irregular, cycle length, heavy/light bleeding, PMS)
What has your cycle been like in recent months/years? What has changed?
When was your last period / menopause?
What illnesses have occurred in your mother, father or older sisters? Are there cases of osteoporosis, heart attacks, dementia or diabetes in the family?
Do / did you have a (chronic) illness?
(e.g. thyroid disease, autoimmune disease, diabetes, other)
Do you take medication regularly?
Do you take dietary supplements?

Part 3: Lifestyle

Do you drink alcohol?
Do you smoke?
How much exercise do you do?
Never
Rarely
less than 2x / month
Sometimes
~1x / week
Often
at least 2x / week
Endurance training / cardio
Strength training
Other sport
Other everyday movement (housework, walking, physical work, ...)
How would you rate your eating habits?
Do you know how much protein you eat per day?
Do you know how much fiber you eat per day?
Do you know how much sugar you consume per day?
On a scale of 0 (no stress at all) to 10 (extreme stress), how would you rate your stress level? Personal + professional.
What methods do you use to manage stress?

Part 4: Wishes & Concerns

What are your biggest concerns regarding perimenopause / menopause?
What burdens you most (beyond the symptoms)?
What have you already done to feel better?
Is there anything else you'd like to tell me?

Space for notes

What was discussed? Goals and plans? Priorities?