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Estrogen & Memory

NY Memory Services
65 East 76th Street
New York, NY 10021

Tel: (212) 517 6881
[email protected]

Estrogen, Menopause & Memory Survey

This survey will take between 5 to 10 minutes to complete.

1. When was your date of birth?  

2. How many years of education have you received?
Less than 8 yrs     8-12 yrs  12-16 yrs   More than 16 yrs

3. What is your race?
African_American Asian      Caucasian Hispanic Other

4. How did you hear about this survey?
I read the book    The Web From a friend
Other (Please specify)   

5. How old were you when you started having your periods?

6. Have your periods changed in flow, cycle or stopped? If NO, skip to question # 10.
Yes    No

7. How old were you when your periods changed in flow or cycle? years

8. If you no longer have periods, how old were you when they stopped completely? years

9. What do you think caused the change in your periods?

    Pregnancy    Beginning of natural menopause

    Hysterectomy    Chemotherapy    

    Other (please specify)

10. Are you experiencing any of the following symptoms?         

    (Check all that apply):

    Cold Sweats/ Hot flashes    Memory Loss

    Vaginal Dryness/ Irritation    Depression/ Anxiety

    Reduced sexual drive            Bladder/Urinary problems

    Other (please specify)

11. Are you or have you ever been on hormone replacement (estrogen or progesterone) therapy? (If NO, skip to question # 19)

    Yes    No

12 .   What is the name and dose of the hormone replacement you are now taking or that you last took?

13.  About how long have you or had you been on this preparation? years.

14.  Is the hormone replacement therapy a 

        Skin patch    Vaginal cream/suppository    Tablet

15.   Approximately how long have you been on hormone replacement altogether? years.

16.     How long do you plan to be on hormone replacement?

17.  Do you or did you have any side effects from hormone replacement therapy?

          Headaches               Vaginal bleeding/ spotting

        Depression                Skin rash/ breakout

        Sleepiness                 Blood clots

        Breast tenderness    Other (specify)

18.  Please rate, from 1 to 3, the top three reasons you are on hormone replacement therapy, with 1 being the most important reason:

        Treatment of hot flashes

        Treatment of bladder or urinary problems

        Treatment of sexual dysfunction

        Treatment of mood and anxiety problems

        Treatment of memory and language problems

        Prevention of osteoporosis and fractures

        Prevention of heart disease and stroke

        Prevention of Alzheimer's disease

        Other (Please specify)  

19.  If you are not now on hormone replacement, why did you decide to not go on, or to stop hormone replacement?

        I have not reached menopause yet

        No symptoms, although I am menopausal

        Fear of breast cancer   

        Have not thought about hormone replacement

        Bad side effects on hormone replacement in the past

        Do not wish to introduce chemicals into the body

        Other (please specify)

20. Where do you think prescription hormone replacements come from?

        plants (wild yam and soy)

        urine of pregnant mares

        synthetic chemicals

        Other (please specify)

21.  Are you taking any of these over the counter menopause treatments?

        Black cohosh    Soy products    

        Donq Quoi         Progesterone creams    

        Other (please specify)

22. Are you taking any of these other over the counter supplements?

        Gingko biloba        Vitamin E        Valerian

        St. John's Wort      Melatonin        Primrose oil

        SAM-e        Other (please specify)      

23.  Are you currently on birth control pills?

       Yes        No

24. Were you ever on birth control pills?

       Yes        No

25. What is the total length of time you have been on birth control pills? years

26. If there is a history of breast cancer in your family, who was affected?

        Mother    Sister    Father/brother    

        Other (Please specify) 

27.  If you have a history of breast disease what type was it?

        Benign    Malignant    No history of breast disease

28.  Have you ever had a breast biopsy? 

        Yes        No

29. How many times have you lost consciousness because of a blow to the head?

        Never        Once        Two or more times

30. Have you noticed any changes in your usual ability to think (If No, skip to question # 38)?

        Yes        No 

31.  Do you have more trouble with your memory than usual?

        Yes        No

32.  Do you have more trouble finding words than usual?

        Yes        No

33.  Has your ability to do mental mathematics changed (like counting out change at a grocery)?

        Yes        No

34.   Do you have more trouble remembering recent events?

        Yes        No

35.   Do you have more trouble recalling lists, such as a shopping list?

        Yes        No

36.   Has anyone else noticed these difficulties about you?

        Yes        No

37.   Have these difficulties interfered with your ability to function? 

        Yes        No

38.   How do you rate your mental capacity now versus your performance before you began to have menopausal symptoms?

         I am functioning at of my usual ability.

39.  Do you feel depressed? 

        Yes        No

39a.  Have you felt depressed most of the time over the last two weeks? 

        Yes        No

40.      If you are not depressed have you lost pleasure doing things that you enjoy? 

        Yes        No

( If you answered YES to either question # 39 or # 40, continue to # 41.  If you answered NO to BOTH questions # 39 and # 40, skip to question # 49).

41.  Do you have trouble sleeping or do you sleep too much?

        Yes        No

42.     Have you gained or lost weight?

        Yes        No

43.  Do you have trouble concentrating? 

        Yes        No

44.  Do you feel tired all the time?

        Yes        No

45.      Do you have feelings of guilt?

        Yes        No 

46.  Do you feel more irritable than usual?

        Yes        No

47.    Do you feel suicidal? Have you ever though of plan?

        Yes        No

48.     Do you ever have your mind play tricks on you when you have heard or see things when no one is around (hallucinate)?

        Yes        No 

49.  Do any of these areas cause more than usual amounts of stress in your life?

        Career        Significant other        Children

        Friends       Other (please specify)

50.  If you knew that prescription hormone replacement was plant-based, would you choose:

        Over the counter hormone replacement

        Prescription hormone replacement

        Don't care either way

51.  Would you mind if we contact with you if we had further questions? Please leave us your e-mail address for further participation

Thanks for your help with this important issue in women's health!

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