Menopause Consultation Patient Questionnaire

Menopause Clinic Pre-Consult Questionnaire

Personal Details

DD slash MM slash YYYY

Medical History

PLEASE GIVE DETAILS – IN PARTICULAR, PLEASE MENTION ANY HISTORY OF BLOOD CLOTS, HEART ISSUES, STROKE OR MIGRAINE OR COELIAC/BOWEL DISEASE.
HAVE YOU EVER BEEN DIAGNOSED WITH ANY BREAST PROBLEMS OR BREAST CANCER?
IF YOU ANSWER YES TO THIS QUESTION, WE CAUTION THAT FURTHER SPECIALIST ADVISE MAY BE REQUIRED AND WE MAY BE UNABLE TO PRESCRIBE HORMONAL TREATMENT – THE DOCTOR WILL DISCUSS THIS WITH YOU AS NECESSARY.
HAVE YOU HAD SURGERY IN THE PAST?
IF YES, WHAT WAS IT FOR AND WHEN WAS IT?
Has anyone in your family been diagnosed with any medical conditions?
PLEASE INSERT NAMES, DOSES AND FREQUENCY OF USE?
Do you have any children?
How many children, year(s) of birth and if vaginal delivery or caesarean section.

Symptom Score Chart

Scoring system 0-3 : ( 0 -not bothersome at all, 1=mild symptoms, 2=moderate symptoms, 3=severe symptoms or N/A=not applicable)

General Issues

Emotional Issues

Bladder Issues

Sexual Problems (if relevant)

Psychological Changes

Period Issue

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