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 | [ ] | [ ] |