Intimate Comfort Tracker

What is your age? (in years)

What is your menopausal status?

Premenopausal (still having regular periods) Perimenopausal (irregular periods, transitioning) Postmenopausal (no periods for 12+ months) Surgical menopause (ovaries removed)

How long has it been since your last menstrual period?

Less than 12 months 1-2 years 3-5 years More than 5 years

Are you currently using hormone therapy?

Yes, systemic (oral / patch / gel) Yes, vaginal only No Previously used, now stopped

Over the past 4 weeks, how OFTEN have you experienced each of the following?

	Never	Rarely (1-2x/month)	Sometimes (1-2x/week)	Often (3-4x/week)	Always (daily)
Vaginal dryness	Never	Rarely (1-2x/month)	Sometimes (1-2x/week)	Often (3-4x/week)	Always (daily)
Vaginal itching / irritation	Never	Rarely (1-2x/month)	Sometimes (1-2x/week)	Often (3-4x/week)	Always (daily)
Vaginal burning / stinging	Never	Rarely (1-2x/month)	Sometimes (1-2x/week)	Often (3-4x/week)	Always (daily)
Vaginal pain / soreness	Never	Rarely (1-2x/month)	Sometimes (1-2x/week)	Often (3-4x/week)	Always (daily)

When present, how SEVERE was each symptom over the past 4 weeks?

	None	Mild	Moderate	Severe	Very severe
Vaginal dryness	None	Mild	Moderate	Severe	Very severe
Vaginal itching / irritation	None	Mild	Moderate	Severe	Very severe
Vaginal burning / stinging	None	Mild	Moderate	Severe	Very severe
Vaginal pain / soreness	None	Mild	Moderate	Severe	Very severe

Over the past 4 weeks, how much have vaginal symptoms impacted each area of daily life?

	No impact	Minimal	Mild	Moderate	Severe
Physical comfort	No impact	Minimal	Mild	Moderate	Severe
Exercise / physical activity	No impact	Minimal	Mild	Moderate	Severe
Clothing choices	No impact	Minimal	Mild	Moderate	Severe
Sleep quality	No impact	Minimal	Mild	Moderate	Severe
Mood / emotional well-being	No impact	Minimal	Mild	Moderate	Severe

How has your interest in sexual activity changed?

No change Slightly decreased Moderately decreased Significantly decreased Completely absent

How comfortable is sexual activity for you?

No discomfort Mild discomfort Moderate discomfort Significant discomfort Severe pain / unable to engage Not sexually active

How much have these symptoms affected your intimate relationship?

How would you rate your overall vaginal comfort in the past 4 weeks?

Excellent (no issues) Very good (minimal issues) Good (some manageable issues) Fair (regular bothersome issues) Poor (constant problematic issues)

How much do vaginal symptoms interfere with your quality of life?

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