Perimenopause / Menopause Intake

Perimenopause / Menopause Intake – NoPauseMD

Please complete this form to help us understand your health history and current symptoms related to perimenopause or menopause.
Full Name
Date of Birth

MonthDayYear
Date
Age
Email Address
example@example.com
Mobile Phone
Address
Emergency Contact Name
Emergency Contact Phone
Preferred Contact Method
Marital Status
Occupation
Hours Worked Per Week
Menarche Age
Typical Cycle Length in Your 20s–30s
Flow in Your 20s–30s
Did you pass clots during your periods?
Describe any clots previously
Current Menstrual Status
Last Menstrual Period

MonthDayYear
Date
Current Flow Amount
Current Bleeding Duration
Are you currently passing clots?
Describe current clots
Number of Pregnancies
Number of Live Births
Number of Miscarriages
Number of Abortions
Any ectopic pregnancies?
Children and ages
History of pregnancy complications?
Gynecologic History
General Medical History
If autoimmune disease, which one?
If cancer, type and treatment
Surgeries
Medication Allergies
Food or Environmental Allergies
Last Pap Smear Date

MonthDayYear
Date
Last Pap Smear Result
Last Mammogram Date

MonthDayYear
Date
Last Mammogram Result
Last Breast Ultrasound

MonthDayYear
Date
Last DEXA Scan

MonthDayYear
Date
DEXA Scan Result
How long have you noticed symptoms related to midlife changes?

Symptom Severity – Rate Each from 1 (very mild) to 10 (severe)

Rows	1	2	3	4	5	6	7	8	9	10
Hot flashes
Night sweats
Chills
Difficulty falling asleep
Difficulty staying asleep
Non-restorative sleep
Mood swings
Anxiety
Irritability
Depression
Brain fog
Memory issues
Difficulty concentrating
Low energy/fatigue
Afternoon crashes
Weight gain
Belly fat increase
Headaches
Migraines
Dizziness/lightheadedness
Tingling or numbness in hands/feet
Constipation
Bloating
Reflux/heartburn
Breast tenderness
Vaginal dryness
Painful intercourse
Low libido
Urinary urgency
Recurrent UTIs
Joint pain
Muscle aches
Stiffness
Feeling “not like myself”
Loss of joy
Loss of purpose
Overwhelm
Heavy bleeding (if still cycling)
Irregular periods (if still cycling)
Flooding episodes (if still cycling)
Severe PMS/PMDD

Which symptoms bother you the most right now?
Treatments you have tried for these symptoms

Other
If other treatments tried, please describe
How did you respond to past treatments?
Top treatment goals in order of urgency (list 1–5)
Stress level on most days

1

2

3

4

5

6

7

8

9

10

1 is , 10 is Best
Main sources of stress
Diet – What did you eat in the last 3 days? Please include breakfast, lunch, dinner, snacks, drinks
Exercise frequency
Type of exercise
Alcohol use
Caffeine intake
Tobacco use
Is there anything else you would like Dr. Thomas to know before your visit?
Patient Information

Tell us about yourself.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical History

Please provide your relevant medical history.
Have you been diagnosed with any of the following conditions?

Other
Please list any surgeries or hospitalizations:
Family history of medical conditions (check all that apply):

Other
Menstrual & Reproductive History

Tell us about your menstrual and reproductive history.
Age at first period
Are your periods currently:

Other
Age at last period (if applicable)
Have you ever used hormone therapy?
If yes, please specify type and duration:
Are you currently using any form of contraception?
If yes, please specify:
Current Symptoms

Please check any symptoms you are currently experiencing.
Which of the following symptoms are you currently experiencing?

Other
Please describe any other symptoms or concerns:
Current Medications & Supplements

List all medications and supplements you are currently taking.
Please list all current medications and supplements (include dosage and frequency):
Allergies

Let us know if you have any allergies.
Do you have any allergies to medications, foods, or other substances?
If yes, please list your allergies:
Lifestyle

Share information about your lifestyle.
Do you smoke?
Do you drink alcohol?
Do you exercise regularly?
If yes, what type and how often?
Consent & Signature

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Perimenopause / Menopause Intake – NoPauseMD

Patient Information

Medical History

Menstrual & Reproductive History

Current Symptoms

Current Medications & Supplements

Allergies

Lifestyle

Consent & Signature