Am I Menopausal?

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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 . If you do not have a blood pressure machine at home, please feel free to use the machine in the side room at reception.

Personal Details

Symptoms

Please indicate the extent to which you are bothered at the moment by the following symptoms, with the options: Never, Sometimes, Often, All the time

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?:

Lifestyle

Smoking Status :

Alcohol Intake:

Exercise:

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:

https://www.balance-menopause.com/

https://www.nhs.uk/conditions/menopause/

Privacy Consent

This form collects personal and medical informanot tion about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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What is HRT?

Types of HRT

Privacy Consent

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