Menopause Virtual Group Consultation Self-Referral Form
Name
*
First Name
Last Name
E-mail - this is how we will contact you.
*
example@example.com
Phone Number
*
Format: 00000000000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
NHS Number
*
NHS number is mandatory https://www.nhs.uk/find-nhs-number/what-is-your-name
Date of Birth
*
-
Day
-
Month
Year
Date
Please select your age from the list below
Please Select
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
Please note this service is only available for patients aged 45-65
Next of Kin & Contact Number
Registered GP Practice
*
Please Select
Adelaide Medical Centre (HIOW)
Alresford Surgery (HIOW)
Bishops Waltham Surgery (HIOW)
Charlton Hill Surgery (HIOW)
Friarsgate Practice (HIOW)
Gratton Surgery (HIOW)
Shepherds Spring Medical Centre (HIOW)
St Clements Partnership (HIOW)
St Mary's Surgery (HIOW)
St Paul's Surgery (HIOW)
Stockbridge Surgery (HIOW)
Stokewood Surgery (HIOW)
The Andover Health Centre Medical Practice (HIOW)
Twyford Surgery (HIOW)
Watercress Medical (Mansfield Park Surgery) (HIOW)
West Meon Surgery (HIOW)
Whitchurch Surgery (HIOW)
Wickham Surgery (HIOW)
Chineham Medical Practice
Shakespeare Road Medical Practice
Camrose, Gillies, Hackwood & Beggarwood
Whitewater Health
Memorable word
*
You will be asked to provide this at your consultation to confirm your identity. Please keep a note of this.
Questionnaire
Before you can attend a group clinic, the clinician needs the following information from you. The clinician and facilitator of the group will be able to access your answers to provide you with care.
Height
*
Weight
*
Latest blood pressure reading (if known)
Latest cholesterol result (if known)
Date of last period (if known)
-
Month
-
Day
Year
Date
Have you had a hysterectomy?
*
Yes
No
If yes, please provide date
-
Month
-
Day
Year
Date
Date of last smear (if known)
-
Month
-
Day
Year
Date
Have you had any gynaecological problems?
How many pregnancies have you had?
How many children do you have?
Have you suffered from post natal depression?
*
Yes
No
Have you had any unusual bleeding, bleeding in between periods or after intercourse?
*
Yes
No
Do you have hot flushes?
*
Yes
No
If yes, when did they start?
-
Month
-
Day
Year
Date
Are you currently on HRT?
*
Yes
No
If yes, when did you start?
-
Month
-
Day
Year
Date
Please list all current medication (including any HRT)
Please detail any drug allergies: name of drug and what reaction was experienced
Please list past medical history and/or Long Term Conditions
Which group are you looking to attend
*
Group Information Session
Group Consultation (Start / Change HRT)
Testosterone (Information / Prescription)
Other
Symptom Checker
To help us with your assessment please indicate the extent in which you are affected by the following symptoms. Please tick as appropriate.
Rows
Not at all
A Little
Quite a lot
Extremely
Heart palpitations
Night sweats
Headaches
Difficulty sleeping
Lack of energy
Tiredness
Feeling unhappy or depressed
Feeling anxious
Crying spells
Mood swings
Irritable
Muscle and joint pains
Vaginal dryness
Pain during sex
Itching of the vulva
Loss of interest in sex
Urinary infections
Passing urine often
Video group clinic registration and agreement:
By participating in this group clinic I agree to the following:
(you must confirm all statements)
*
To confirm that you understand the Group Clinic Agreement, wish to attend the menopause group clinic, and consent to MHH accessing my medical records, please sign here
*
Submit
Should be Empty: