Patient Questionnaire Prior to Menopause Consultation
Please complete this form prior to your menopause consultation to help us understand your health history and current symptoms.
PERSONAL DETAILS
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
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MENSTRUAL HISTORY & MENOPAUSE SYMPTOMS
Are your periods regular?
*
Yes
No
Are your periods heavy?
Yes
No
Are your periods painful?
*
Yes
No
Are you using any contraception?
Yes
No
If yes, please specify
Are you sexually active?
Yes
No
Have you had children?
Yes
No
If yes, how many?
Are you experiencing any of the following symptoms? Please indicate severity (0 = not present, 10 = severe)
Rows
Severity (0-10)
Hot flushes / Sweats
Excess fatigue
Difficulty sleeping
Memory or concentration problems "Brain fog"
More aches/pains than usual
Difficulty losing/maintaining weight
Breast pains
Migraine/headaches
Chest pains or heart palpitations
Low mood/depression
Increased anxiety levels
Loss of interest in sex
Painful sex
Unexpected vaginal bleeding e.g. bleeding after sex
Vaginal dryness
Needing to pass urine more often or pain on passing urine
What symptoms bother you the most?
Any other symptoms you think may be related to menopause?
Have you tried any complimentary/alternative therapies to help with your symptoms?
Yes
No
What therapies would you consider?
Over the counter suppliments
Prescribed hormonal replacement therapy (HRT)
Prescribed hormonal replacement therapy
Tanking therapies
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PAST MEDICAL HISTORY
Have you had any difficulty taking any hormonal medications before e.g. contraception?
Yes
No
Please indicate below if there is any history of the following:
Breast Cancer (Me)
Yes
No
Blood clot in a leg or lung (Me)
Yes
No
Stroke (Me)
Yes
No
Heart disease (Me)
Yes
No
Breast Cancer (Family)
Yes
No
Blood clot in a leg or lung (Family)
Yes
No
Stroke (Family)
Yes
No
Heart disease (Family)
Yes
No
Osteoporosis (Me)
Yes
No
Migraine headache (Me)
Yes
No
Osteoporosis (Family)
Yes
No
Migraine headache (Family)
Yes
No
Any other cancers? (Me)
Yes
No
Any other cancers? (Family)
Yes
No
GYNAECOLOGY
Previous pregnancies/gynaecology issues?
When was your last smear?
When was your last mammogram?
When was your last DEXA?
Do you smoke?
Yes
No
Do you drink alcohol?
Yes
No
Have you used any Hormone replacement therapy before (oral, patch, vaginal)?
Yes
No
Please list any regular medications or supplements you take?
Do you exercise regularly?
Yes
No
If yes, what type and how often?
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Has anyone in your family had any of the following?
Breast cancer
Ovarian cancer
Blood clot (DVT/PE)
Heart disease
Stroke
Other
Anything else you would like to discuss at your consultation?
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Submit
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