Menopause Questionnaire

Please complete this questionnaire if you are aged 45-55 years old and think that you are having menopausal symptoms. By answering this questionnaire your clinician will have a better understanding of your general health and symptoms prior to seeing you for a consultation.

Please see the following links for further information about HRT that you may find useful:

• Menopause Matters – www.menopausematters.co.uk
• NHS – www.nhs.uk/conditions/menopause
• Patient.info Menopause – patient.info/womens-health/menopause
• Patient.info HRT – patient.info/womens-health/menopause/hormone-replacement-therapy-hrt
• Patient.info Alternatives to HRT – patient.info/womens-health/menopause/alternatives-to-hrt

Please see the following links for further information about HRT & Breast Cancer that you may find useful:

• MHRA HRT & Breast Cancer (PDF)

Menopause Questionnaire

If you are human, leave this field blank.

Section

Greene Scores

Please first calculate your symptom scores by visiting:

Menopause Matters: Greene Score

Select "Calculate my score" to display all your readings in the table at the bottom of the page, then enter these numbers below:

What is your Greene score for Anxiety symptoms? *

What is your Greene score for Depression symptoms? *

What is your Greene score for Sexual symptoms? *

What is your Greene score for Psychological symptoms? *

What is your Greene score for Physical symptoms? *

What is your Greene score for Vasomotor symptoms? *

Alcohol Consumption

Lifestyle factors have a large impact on your risks of developing chronic health conditions and cancers.

This is one unit of alcohol:

And each one of these, is more than one unit:

How often do you have a drink containing alcohol? *

Never

Monthly or less

2-4 times per month

2-3 times per week

4+ times per week

How many units of alcohol do you drink on a typical day when you are drinking? *

1-2

3-4

5-6

7-9

10+

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Smoking

Do you smoke? *

Never smoked

Ex-smoker

Trivial smoker (lass than 1 cigarette per day)

Light smoker (1-9 cigarettes per day)

Moderate smoker (10-19 cigarettes per day)

Heavy smoker (20-39 cigarettes per day)

Very heavy smoker (40 or more cigarettes per day)

Do you use an e-cigarette? *

Yes

No

Ex-user

Would you like help to quit smoking? *

Yes

No

For further information, please visit NHS Smokefree.

NHS Health Check

Have you had an NHS Health Check in the last 5 years? *

Yes

No

Please book an appointment with reception for an NHS Health Check, prior to seeing a clinician about the menopause.

Medical History

If you are under 50 years of age and it has been less than 2 years since your last period, when was your last natural period?

If you are over 50 years of age and it has been less than 1 year since your last period, when was your last natural period?

Have you had a hysterectomy? *

Yes

No

Have you had a Mirena coil (intrauterine system, IUS) fitted? *

Yes

No

What date was your Mirena coil fitted? *

What is your current weight (kg)? *

What is your current height (metres)? *

What is your current heart rate/pulse rate? (bpm)

If you have taken your blood pressure, what is your current systolic blood pressure? (the larger number) (mmHg)

If you have taken your blood pressure, what is your current diastolic blood pressure? (the smaller number) (mmHg)

Are you "breast aware"? *

Yes

No

For more information: Breast Cancer UK: Check your breasts

Are you up to date with your mammograms? *

Yes

No

Not applicable

Have you ever had any bloods clots? (e.g. Deep Vein Thrombosis or Pulmonary Embolism) *

Yes

No

Have you ever had a heart attack or stroke? *

Yes

No

Have you ever had breast cancer or endometrial cancer? *

Yes

No

Have you ever had liver or gallbladder disease? *

Yes

No

Do you have a family history of any of the following?

Blood clots (e.g. Deep Vein Thrombosis or Pulmonary Embolism)

Breast Cancer

Endometrial cancer

Heart Attack

Stroke

None of the above

Please select all that apply

Are you currently using contraception? You may still require contraception upto the age of 55 yrs. HRT does not provide contraceptive cover. *

No, because I am over 50 and my last period was over 1 year ago

No, because I am under 50 and my last period was over 2 years ago

No, because I am over 55

No

Yes

Provide details of your current contraception: *

Further Questions

I have the following questions that I would like to raise with about HRT with my Nurse or Doctor:

I have already researched HRT and my preferred HRT is:

*

By completing this questionnaire, I confirm that all of the information is correct

Submit