Peri-menopause & Menopause Questionnaire
Name
First Name
Last Name
Email
example@example.com
Phone number
Date of Birth
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
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12
13
14
15
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31
Day
Please select a year
0
01
011
0111
01111
Year
Weight in kgs
Enter your weight in kilograms
Height
Enter your height
When was your last period?
Are you in peri-menopause or full menopause? (menopause is defined as having no period for a full 12 months)
peri-menopause
full menopause
What symptoms are you experiencing? Tick all that apply.
hot flashes
night sweats
low mood
irritability
anxiety
brain fog
weight gain
vaginal dryness
bladder issues
headaches
dry skin
hair loss
Describe a typical day's meals, including drinks and times.
Do you follow a special diet? (If yes, please give details below)
How many portions of fish do you eat per week?
How many portions of green vegetables do you eat per week?
How many portions of wholegrains (oats, wholegrain bread, brown rice etc) do you eat per week?
How many portions of fruit do you eat per week?
How many portions of dairy do you eat per week?
Do you have any allergies? (if yes, please give details below)
Are there any foods that you hate and avoid completely? (If yes, please give details below)
Do you take any supplements? (If yes, please give details below)
Do you have any medical conditions? (If yes, please give details below)
Do you take any prescription medications? (If yes, please give details below)
Do you suffer from any of the following digestive issues?
indigestion
constipation
diarrhea
bloating
gassiness
Is there anything else you'd like to share?
Submit
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