Menopause Health Questionnaire

NAMS

THE NORTH AMERICAN MENOPAUSE SOCIETY
Menopause Health Questionnaire
Menopause is a normal event in a woman's life and is marked by the end of menstrual periods. Usually during the 40s, a gradual process leading to menopause begins. This is called the menopause transition or perimenopause. Changes in the pattern of menstrual periods are very common during this stage. Sometimes a woman can have other symptoms too, and these symptoms may extend beyond menopause. Even if a woman has no symptoms, it's important for her to understand the effects of menopause on her health.

This questionnaire is intended to help you inform your healthcare provider about your menopause experience and your general health. Working together, you can develop a plan to support your health, not only now but also in years to come. If you feel uncomfortable answering any of the questions on this form, you may wait and discuss them with your healthcare provider.
PERSONAL INFORMATION
Date*

MonthDayYear
Date
Name*
Birth date*

MonthDayYear
Date
Age
Ethnic/cultural background (please check what applies to you):

CaucasianBlackAsianNative AmericanBiracialHispanic/LatinaOther
Name of primary support person
Relationship
Primary support person telephone number
Are you on medical leave?

YesNo
If yes, why?
For how long?
TODAY'S OFFICE VISIT
Why are you here today?
What are your main concerns or questions you would like to have answered during your visit?
Who referred you?
GYNECOLOGIC HISTORY
How would you describe your current menstrual status?

Premenopause (before menopause; having regular periods)Perimenopause/menopause transition (changes in periods, but have not gone 12 months in a row without a period)Postmenopause (after menopause)
Was your menopause (if applicable):

Spontaneous ("natural")Surgical (removal of both ovaries)Due to chemotherapy or radiation therapyOther (explain)
Reason for chemotherapy or radiation therapy (if applicable)
Age at first menstrual period
Are your periods (or were your periods) usually regular?

YesNo
Do you have a uterus?

YesNoDon't know
Do you have both ovaries?

YesNoDon't know
Do you have a cervix?

YesNoDon't know
If not still having periods, what was your age when you had your last period?
If still having periods, how often do they occur?
How many days does your period last?
Are your periods painful?

YesNo
If yes, how painful?

MildModerateSevere
Do you have spotting or bleeding between periods?

YesNo
Is there a recent change in how often you have periods?

YesNo
Is there a recent change in how many days you bleed?

YesNo
Has your period recently become very heavy?

YesNo
Do you think you have a problem with your period?

YesNo
If yes, explain
Do you have any problems with PMS? (PMS is having mood swings, bloating, headaches just prior to your period)

YesNo
Do you examine your breasts?

YesNo
If yes, how often?
Did your mother take DES when she was pregnant with you?

YesNoDon't know
Do you douche?

YesNo
If yes, how often?
What is the date and results (if known) of your last test regarding:
Pap smear
Any abnormal pap tests?

YesNo
If yes, when?
Mammogram
Any breast biopsies?

YesNo
If yes, when?
Thyroid
Any abnormal thyroid tests?

YesNo
If yes, when?
Cholesterol test
Colonoscopy
Blood sugar test
Sigmoidoscopy
Fecal occult blood test
Bone density test
OBSTETRICAL HISTORY

Please indicate the method of birth control, if any, that you are currently using or have used previously:

	Using Now	Previously Used
None
Sterilization (tubed tied)
Male partner had vasectomy
Birth control pill, ring, or skin patch
IUD
Injectable hormone
Implanted hormone
Diaphragm
Foam/gel
Condoms
Natural family planning/rhythm
Other

How many times have you been pregnant?
How many children do you have?
How many were adopted?
How old were you when you first child was born?
How old were you when your last child was born?
Please provide the number of your:
Full term births
Premature births
Miscarriages
Abortions
Living children
Any complications during pregnancy, delivery, or postpartum?

YesNo
If yes, please describe
SEXUAL HISTORY
Are you currently sexually active?

YesNo
If yes, are you currently having sex with:

A man (or men)A woman (or women)Both men and women
In the past, have you had sex with:

A man (or men)A woman (or women)
How long have you been with your current sex partner?

Sexual History

	Yes	No
Are you in a committed, mutually monogamous relationship?
If no, do you use condoms (practice safe sex)?
Have you had any sexually transmitted infections?
Do you have concerns about your sex life?
Do you have a loss of interest in sexual activities (libido, desire)?
Do you have a loss of arousal (tingling in the genitals or breasts; vaginal moisture, warmth)?
Do you have a loss of response (weaker or absent orgasm)?

Any complications during pregnancy, delivery, or postpartum?

YesNo
Do you have any pain with intercourse (vaginal penetration)?

YesNo
If yes, how long ago did the pain start?
Please describe the pain

Pain with penetrationPain insideFeels dry
PERSONAL HABITS
Do you consider your health to be:

ExcellentGoodFairPoor
Diet
How many meals do you consume each day?
Do you try to eat a special diet?

Low-fatLow carbohydrateHigh proteinVegetarian

What dairy products do you consume each day?

	Yes	How much?
Milk
Yogurt
Cheese
Other

Are you lactose intolerant (diarrhea or gastrointestinal/GI upset after dairy products)?

YesNo
How many servings of fruits do you consume each day?
How many servings of vegetables do you consume each day?
How many servings of soy foods do you consume each week?
How many servings of fish do you consume each week?
Caffeine Use
Do you consume drinks with caffeine (coffee, tea, soda drinks)?

YesNo
If yes, how many drinks each day?
Abuse

	Yes	No
Within the last year, have you been hit, slapped, kicked,or physically hurt by someone?
Within the last year, has anyone ever forced you to have sexual activities?
Do you feel you are verbally or emotionally abused by someone?
Have you had counseling for these issues?

Stress management
What are the current major stressors or life changes in your life?
Any major changes in the family health during the past year?

YesNo
If yes, explain:
How do you handle stress?

Very WellModerately wellPoorly
What do you do to relax?
SYMPTOMS

Please indicate how bothered you are now and in the past few weeks by any of the following:

	Not at all	A little bit	Quite a bit	Extremely
I have hot flashes
I have night sweats
I have difficulty getting to sleep
I have difficulty staying asleep
I get heart palpitations or a sensation of butterflies in my chest or stomach
I feel like my skin is crawling or itching
I feel more tired than usual
I have difficulty concentrating
My memory is poor
I am more irritable than usual
I feel more anxious than usual
I have more depressed moods
I am having mood swings
I have crying spells
I have headaches
I need to urinate more often than usual
I leak urine
I have pain or burning when urinating
I have bladder infections
I have uncontrollable loss of stool or gas
My vagina is dry
I have vaginal itching
I have an abnormal vaginal discharge
I have vaginal infections
I have pain during intercourse
I have pain inside during intercourse
I have bleeding after intercourse
I lack desire or interest in sexual activity
I have difficulty achieving orgasm
My opportunity for sexual activity is limited
My stomach feels like it's bloated or I've gained weight
I have breast tenderness
I have joint pains

Is there anything else you would like your healthcare provider to know? *
Thank you! Please note that the information you have provided will be held in the strictest confidence.

American Menopause Society has provided this form as a service to the healthcare community based on the best understanding of the science related to menopause at the time of publication, but the form should be used with the clear understanding that continued research may result in new knowledge and recommendations. This form is provided only as a diagnostic assist to practitioners making clinical decisions health of women in their care. Its contents provide guidance and, as such, it cannot substitute for the individual judgment brought to each clinical situation by the caregiver with respect to any additional data that may be required in order to make appropriate clinical decisions. Menopause Society is not responsible nor liable for any advice, diagnosis, course of treatment, or drug or device application based on the healthcare provider's use of this form.

Copyright © 2005, The North American Menopause Society. All rights reserved. The North American Menopause Society (NAMS), PO Box 94527, Cleveland, OH 44101, USA. Permission is granted by NAMS to reproduce this evaluation form, in whole or in part, for use in clinical practice. Published July 2005.
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NAMS

Menopause Health Questionnaire

PERSONAL INFORMATION

TODAY'S OFFICE VISIT

GYNECOLOGIC HISTORY

What is the date and results (if known) of your last test regarding:

OBSTETRICAL HISTORY

Please provide the number of your:

SEXUAL HISTORY

PERSONAL HABITS

SYMPTOMS