Books on Memory
Estrogen & Memory
NY Memory Services 65 East 76th Street New York, NY 10021 Tel: (212) 517 6881 [email protected]
Estrogen, Menopause & Memory Survey
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? years
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
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? years.
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
20. Where do you think prescription hormone replacements come from?
plants (wild yam and soy)
urine of pregnant mares
synthetic chemicals
21. Are you taking any of these over the counter menopause treatments?
Black cohosh Soy products
Donq Quoi Progesterone creams
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?
24. Were you ever on birth control pills?
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
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?
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)?
31. Do you have more trouble with your memory than usual?
32. Do you have more trouble finding words than usual?
33. Has your ability to do mental mathematics changed (like counting out change at a grocery)?
34. Do you have more trouble remembering recent events?
35. Do you have more trouble recalling lists, such as a shopping list?
36. Has anyone else noticed these difficulties about you?
37. Have these difficulties interfered with your ability to function?
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?
39a. Have you felt depressed most of the time over the last two weeks?
40. If you are not depressed have you lost pleasure doing things that you enjoy?
( 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?
42. Have you gained or lost weight?
43. Do you have trouble concentrating?
44. Do you feel tired all the time?
45. Do you have feelings of guilt?
46. Do you feel more irritable than usual?
47. Do you feel suicidal? Have you ever though of plan?
48. Do you ever have your mind play tricks on you when you have heard or see things when no one is around (hallucinate)?
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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