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 DetailsName First Last Date of Birth Day Month Year PhoneHeight Weight What is your most recent blood pressure? (If known): SymptomsPlease indicate the extent to which you are bothered at the moment by the following symptoms Feeling Anxious Never Sometimes Often All the time Mood swings and irritability Never Sometimes Often All the time Difficulty in sleeping Never Sometimes Often All the time Difficulty in concentrating and brain fog Never Sometimes Often All the time Feeling tired or lacking in energy Never Sometimes Often All the time Lacking in motivation Never Sometimes Often All the time Feeling low in mood Never Sometimes Often All the time Heart beating strongly or quickly Never Sometimes Often All the time Joint Pain Never Sometimes Often All the time Muscle aches and pains Never Sometimes Often All the time Headaches or Migranes Never Sometimes Often All the time Breathing Difficulties Never Sometimes Often All the time Numbness, pins and needles, itching or prickling sensation to skin Never Sometimes Often All the time Feeling dizzy or faint Never Sometimes Often All the time Dry Skin Never Sometimes Often All the time Hot Flushes Never Sometimes Often All the time Night Sweats Never Sometimes Often All the time Vaginal dryness, irritation or pain during sex Never Sometimes Often All the time Recurrent urinary tract infections or urinary incontinence Never Sometimes Often All the time Loss of interest in sex Never Sometimes Often All the time Have you had to take any time off work due to your symptoms?: Yes No N/A Have you had a period in the last year? Yes No Are you currently using contraception? Yes No Do you require ongoing contraception? Yes No 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? Yes No Do you have a first degree relative (parent or sibling) that has had breast cancer under the age of 50? Yes No Has a first degree family member (parent, sibling or child) ever had a blood clot? Yes No Have you ever had a blood clot? Yes No Do you have any blood clotting abnormalities? Yes No Have you previously had breast cancer? Yes No Do you experience migraines? Yes No Do you have active liver disease? Yes No LifestyleSmoking Status Current Smoker Ex-Smoker Never Smoked Exercise More than 3 times a week A few times a week Rarely Never Have you got any ideas of particular concerns surrounding the menopause and HRT?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 HRTThere 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: https://www.balance-menopause.com/ https://www.nhs.uk/conditions/menopause/
