Menopause Symptom Questionnaire

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Completing this form will help you and the clinician prepare, guide the clinician to the best HRT choices and allow more time for you in your appointment

Personal Details

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May be used to identify you

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Questions

Heartbeat quickening, racing or palpitations: *

Trouble breathing: *

Feeling faint/dizzy: *

Pins and needles anywhere in your body: *

Pressure or tightness in body: *

Tinnitus ear ringing: *

Joint/muscle pains: *

Headaches: *

Hot flushes: *

Sweating at night: *

Difficulty sleeping: *

Feeling tired/lacking energy/fatigue: *

Loss of interest/lack of motivation: *

Difficulty concentrating: *

Memory problems: *

Feeling nervous: *

Emotional: *

Anxiety/panic attacks: *

Feeling low in mood, or depressed: *

Crying spells: *

Easily irritated: *

Reduced/loss of sex drive: *

Vaginal dryness: *

Urinary symptoms: *

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Medical History

Have you ever had gynaecological surgery (including hysterectomy)?: *

Are you currently using any form of contraception?: *

Are you currently on HRT?: *

Do you smoke/ have you ever smoked?: *

Have you ever had: a migraine, blood clot (e.g. deep vein thrombosis, pulmonary embolism, stroke), high blood pressure or heart problems: *

Have any of your relatives had ovarian or breast cancer?: *

Do you use any complementary therapies (e.g. St. John’s wort), or unprescribed medication/drugs?: *

Do you currently take any vitamin D supplements?: *

If you are unable to take your blood pressure please skip this question

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Menopause Symptom Questionnaire

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