Menopause Quality of Life Questionnaire

The Menopause-Specific Quality of Life Questionnaire is a self-report measure assessing the presence and severity of symptoms. This questionnaire is based on many research studies and has proven to be a validated and standardized way of assessing severity of menopause symptoms and the degree to which they adversely affect your life.

Use this questionnaire to assess your symptoms prior to starting hormone replacement therapy and then during to track your progress. As you undergo treatment, your total score should decrease, indicating that symptoms have resolved or decreased in severity.

For each of the items below, indicate by checking “Yes” or “No” whether you have experienced the problem in the PAST WEEK. If you have, rate the degree to which you have been bothered by the problem: 1 = not at all bothered, 6 = extremely bothered.

#	Problem	No	Yes — how much bothered (1–6)
1	Hot flashes or flashes	No	1	2	3	4	5	6
2	Night sweats	No	1	2	3	4	5	6
3	Sweating	No	1	2	3	4	5	6
4	Dissatisfaction with my personal life	No	1	2	3	4	5	6
5	Feeling anxious or nervous	No	1	2	3	4	5	6
6	Poor memory	No	1	2	3	4	5	6
7	Accomplishing less than I used to	No	1	2	3	4	5	6
8	Feeling depressed, down or blue	No	1	2	3	4	5	6
9	Being impatient with other people	No	1	2	3	4	5	6
10	Feelings of wanting to be alone	No	1	2	3	4	5	6
11	Flatulence (wind) or gas pains	No	1	2	3	4	5	6
12	Aching in muscles and joints	No	1	2	3	4	5	6
13	Feeling tired or worn out	No	1	2	3	4	5	6
14	Difficulty sleeping	No	1	2	3	4	5	6
15	Aches in back of neck or head	No	1	2	3	4	5	6
16	Decrease in physical strength	No	1	2	3	4	5	6
17	Decrease in stamina	No	1	2	3	4	5	6
18	Lack of energy	No	1	2	3	4	5	6
19	Dry skin	No	1	2	3	4	5	6
20	Weight gain	No	1	2	3	4	5	6
21	Increased facial hair	No	1	2	3	4	5	6
22	Changes in appearance, texture or tone of my skin	No	1	2	3	4	5	6
23	Feeling bloated	No	1	2	3	4	5	6
24	Low backache	No	1	2	3	4	5	6
25	Frequent urination	No	1	2	3	4	5	6
26	Involuntary urination when laughing or coughing	No	1	2	3	4	5	6
27	Decrease in my sexual desire	No	1	2	3	4	5	6
28	Vaginal dryness	No	1	2	3	4	5	6
29	Avoiding intimacy	No	1	2	3	4	5	6
30	Breast pain or tenderness	No	1	2	3	4	5	6
31	Vaginal bleeding or spotting	No	1	2	3	4	5	6
32	Leg pains or cramps	No	1	2	3	4	5	6

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