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*
     / /
  • Birth date*
     / /
  • Ethnic/cultural background (please check what applies to you):
  • Format: (000) 000-0000.
  • Are you on medical leave?

  • TODAY'S OFFICE VISIT

  • GYNECOLOGIC HISTORY

  • How would you describe your current menstrual status?
  • Was your menopause (if applicable):
  • Are your periods (or were your periods) usually regular?
  • Do you have a uterus?
  • Do you have both ovaries?
  • Do you have a cervix?
  • Are your periods painful?
  • If yes, how painful?
  • Do you have spotting or bleeding between periods?
  • Is there a recent change in how often you have periods?
  • Is there a recent change in how many days you bleed?
  • Has your period recently become very heavy?
  • Do you think you have a problem with your period?
  • Do you have any problems with PMS? (PMS is having mood swings, bloating, headaches just prior to your period)
  • Do you examine your breasts?
  • Did your mother take DES when she was pregnant with you?
  • Do you douche?

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

  • Any abnormal pap tests?
  • Any breast biopsies?
  • Any abnormal thyroid tests?

  • OBSTETRICAL HISTORY

  • Rows

  • Please provide the number of your:

  • Any complications during pregnancy, delivery, or postpartum?

  • SEXUAL HISTORY

  • Are you currently sexually active?
  • If yes, are you currently having sex with:
  • In the past, have you had sex with:
  • Rows
  • Any complications during pregnancy, delivery, or postpartum?
  • Do you have any pain with intercourse (vaginal penetration)?
  • Please describe the pain

  • PERSONAL HABITS

  • Do you consider your health to be:

  • Diet

  • Do you try to eat a special diet?
  • Rows
  • Are you lactose intolerant (diarrhea or gastrointestinal/GI upset after dairy products)?

  • Caffeine Use

  • Do you consume drinks with caffeine (coffee, tea, soda drinks)?

  • Abuse

  • Rows

  • Stress management

  • Any major changes in the family health during the past year?
  • How do you handle stress?

  • SYMPTOMS

  • Rows

  • 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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