• 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

  • Date of Birth
     - -
  • Format: (000) 000-0000.
  • How do you view menopause?*
  • What are your current views regarding hormone therapy for menopause?*
  • How would you rate your knowledge about menopause?

  • Symptoms

  • In the past month, have you been bothered by any of the following? (please check all that apply)

  • Gyencologic History

  • If still having periods, please indicate first day of last menstrual cycle
     - -
  • Are your periods painful?*
  • Do you have spotting or bleeding between periods?*
  • Is there are recent change in how often you have periods?*
  • Is there are recent change in how many days you bleed?*
  • Has your period recently become very heavy?*
  • Do you experience mood swings, bloating, or headaches just prior to your period?*
  • Do you have a uterus?*
  • Do you have a cervix?*
  • Do you have both ovaries?*

  • Medications

  • Allergies

  • Do you have any allergies to medications?*
  • Do you carry an Epi-pen or have been prescribed an Epi-pen?*
  • If YES, have you ever had to use your Epi-pen?

  • Family History

  • Has anyone in your family been diagnosed with any of the following? (please check all that apply)

  • Past Medical History

  • Please check if you have had problems with:*

  • The Menopause Rating Scale (MRS) is a tool used to assess the severity of menopausal symptoms and their impact on a woman's quality of life. It helps in understanding the specific symptoms and their intensity, potentially guiding treatment decisions.  The total score from the MRS can be used to categorize the severity of menopausal symptoms, with higher scores indicating more severe symptoms. The MRS can also be used to track the effectiveness of treatment over time.

  • Please indicate the extent to which you are bothered at the moment by any of these 11 symptoms.

  • 1. Hot flushes, episodes of sweating*
  • 2. Heart discomfort (unusual awareness of heart beat, heart skipping, heart racing, tightness)*
  • 3. Sleep problems (difficulty in falling asleep, difficulty in sleeping through the night, waking up early)*
  • 4. Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings)*
  • 5. Irritability (feeling nervous, inner tension, feeling aggressive)*
  • 6. Anxiety (inner restlessness, feeling panicky)*
  • 7. Physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness)*
  • 8. Sexual problems (change in sexual drive, in sexual activity, and satisfaction)*
  • 9. Bladder problems (difficulty in urinating, increased need to urinate, urinary leakage)*
  • 10. Dryness of vagina (sensation of dryness or burning in the vagina, difficulty with sexual intercourse)*
  • 11. Joint and muscular discomfort (pain in the joints, rheumatoid complaints)*
  • Should be Empty: