Menopause Consultation Patient Questionnaire

Personal Details

DD slash MM slash YYYY
Do you consent for us to notify your own GP of consultation outcome?

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 issues 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 gynaecological surgery in the past?
IF YES, WHAT WAS IT FOR AND WHEN WAS IT?
Has anyone in your immediate family (ie. mother or sister) been diagnosed with any of the following medical conditions?
Has anyone in your immediate family been diagnosed with any of the following 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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