First name

Last name

Birthday

Day

Month

Year

What are your most bothersome menopausal symptoms?

Are you on treatment for your menopause currently and if so, how has it improved your symptoms, and are there any side effects?

Have any of your close family members had any of the following health issues. Please tick which is appropriate.

Lifestyle

Do you smoke? If so what do you smoke and how much?

Do you exercise? If so what type and how often?

Do you drink alcohol? If so how many units a week?

Do you take recreational drugs?

Bone health

Have you had a DEXA scan?

Have you ever broken a bone?

Did either of your parents break a hip?

Did you ever have long term steroid treatment?

Breast cancer risk assessment

Have you had breast cancer?

Have any close family members had breast cancer or ovarian cancer, and if so, at what age were they diagnosed?

What age were you when you had your first baby if any?

Have you ever had a breast biopsy?

Yes

No

Gynaecology history

What age did you get your first period?

Are you currently getting periods?

Yes

No

Have your periods changed?

What was/is your period pattern like? Regular or irregular? Heavy or painful?

What age did your periods stop?

Any history of PMS?

Yes

No

Any history of endometriosis?

Yes

No

Previous pregnancies?

Any history of miscarriage?

Any history of fertility treatment?

Any history of postnatal depression?

Have you had regular smears and are they normal or abnormal?

Did you have any problems with contraception?

Are you sexually active?

Have you ever seen a women's health physiotherapist?

Symptom checker

Vasomotor

Hot flushes

Night sweats

Menopause Assessment Questionnaire

Lifestyle

Bone health

Breast cancer risk assessment

Gynaecology history

Symptom checker