Yes	No
1.	Stomach pain	[ ]	[ ]
2.	Back pain	[ ]	[ ]
3.	Pain in your arms, legs, or joints (knees, hips, etc)	[ ]	[ ]
4.	Menstrual pain or problems	[ ]	[ ]
5.	Pain or problems during sexual intercourse	[ ]	[ ]
6.	Headaches	[ ]	[ ]
7.	Chest pain	[ ]	[ ]
8.	Dizziness	[ ]	[ ]
9.	Fainting spells	[ ]	[ ]
10.	Feeling your heart pound or race	[ ]	[ ]
11.	Shortness of breath	[ ]	[ ]
12.	Constipation, loose bowels, or diarrhoea	[ ]	[ ]
13.	Nausea, gas, or indigestion	[ ]	[ ]
14.	Feeling tired or having low energy	[ ]	[ ]
15.	Trouble sleeping	[ ]	[ ]