Am I Menopausal?

Please complete our short form below. Once your form has been submitted, please allow up to two weeks for a doctor to review your answers. You will receive a telephone call to discuss your answers and explore your options for treatment.

Personal Details

Date of Birth


Please indicate the extent to which you are bothered at the moment by the following symptoms
Feeling Anxious
Mood swings and irritability
Difficulty in sleeping
Difficulty in concentrating and brain fog
Feeling tired or lacking in energy
Lacking in motivation
Feeling low in mood
Heart beating strongly or quickly
Joint Pain
Muscle aches and pains
Headaches or Migranes
Breathing Difficulties
Numbness, pins and needles, itching or prickling sensation to skin
Feeling dizzy or faint
Dry Skin
Hot Flushes
Night Sweats
Vaginal dryness, irritation or pain during sex
Recurrent urinary tract infections or urinary incontinence
Loss of interest in sex
Have you had to take any time off work due to your symptoms?:
Have you had a period in the last year?
Are you currently using contraception?
Do you require ongoing contraception?
Please note: Contraception is recommended for all sexually active women under the age of 55, unless your periods have stopped off hormones for 1 year over the age of 50 or 2 years under the age of 50
Have you had a hysterectomy?
Do you have a first degree relative (parent or sibling) that has had breast cancer under the age of 50?
Has a first degree family member (parent, sibling or child) ever had a blood clot?
Have you ever had a blood clot?
Do you have any blood clotting abnormalities?
Have you previously had breast cancer?
Do you experience migraines?
Do you have active liver disease?


Smoking Status

What is HRT?

HRT is a hormone treatment used to replace hormones your body is no longer producing when you enter the perimenopause or menopause. This includes the hormone oestrogen and often progestogen. If you have a uterus, you will need to take progestogen in combination with oestrogen to protect the lining of your womb.

Types of HRT

There are many different preparations of HRT. The oestrogen component of HRT can be taken as an oral tablet, or given as a patch, gel or spray. Progestogen can be given as an oral tablet, through the mirena coil or combined in a patch with oestrogen.

The benefits of HRT outweigh the risks for most women, however please note you may not be suitable for certain types of HRT

Please have a look at the following website for more information prior to your telephone consultation: