Pre-consultation: Menopause

First name *

Last name *

Email *

Phone *

Date of birth *

What is your current menstrual status? *

Regular periods

Irregular periods - becoming less frequent

No periods for 3-12 months

No periods for over 12 months

Surgical menopause - hysterectomy

Surgical menopause - bilateral oophorectomy

Hot flushes *

Not at all

A little

Quite a bit

Extremely

Sweating episodes *

Not at all

A little

Quite a bit

Extremely

Night sweats *

Not at all

A little

Quite a bit

Extremely

Heart beating quickly or strongly / palpitations *

Not at all

A little

Quite a bit

Extremely

Feeling tense or nervous *

Not at all

A little

Quite a bit

Extremely

Difficulty sleeping *

Not at all

A little

Quite a bit

Extremely

Feeling excitable *

Not at all

A little

Quite a bit

Extremely

Panic attacks *

Not at all

A little

Quite a bit

Extremely

Feeling tired or lacking energy *

Not at all

A little

Quite a bit

Extremely

Difficulty concentrating *

Not at all

A little

Quite a bit

Extremely

Loss of interest in things *

Not at all

A little

Quite a bit

Extremely

Feeling unhappy or depressed *

Not at all

A little

Quite a bit

Extremely

Crying spells *

Not at all

A little

Quite a bit

Extremely

Irritability *

Not at all

A little

Quite a bit

Extremely

Feeling dizzy or faint *

Not at all

A little

Quite a bit

Extremely

Pressure or tightness in head *

Not at all

A little

Quite a bit

Extremely

Parts of body feel numb or tingling *

Not at all

A little

Quite a bit

Extremely

Headaches *

Not at all

A little

Quite a bit

Extremely

Muscle or joint pains *

Not at all

A little

Quite a bit

Extremely

Loss of feeling in hands or feet *

Not at all

A little

Quite a bit

Extremely

Loss of interest in sex *

Not at all

A little

Quite a bit

Extremely

Vaginal dryness *

Not at all

A little

Quite a bit

Extremely

Which symptoms bother you most?

Hot flushes

Night sweats

Sleep disruption

Mood changes

Brain fog / memory problems

Vaginal dryness

Low libido

Joint pain

Weight gain

Fatigue

Anxiety

Other

Have you ever had a blood clot (DVT - in leg) or pulmonary embolism (PE - in lungs)? *

Yes

No

Not sure

Have you or a close family member had breast cancer? *

Yes

No

Not sure

Have you had a stroke or heart attack? *

Yes

No

Not sure

Do you have migraine with aura (flashing lights or visual disturbances before headache)? *

CRITICAL - Combined HRT may increase stroke risk if you have migraine with aura

Yes

No

Not sure

Have you had liver disease? *

Yes

No

Not sure

Do you have any unexplained vaginal bleeding? *

Yes

No

Current blood pressure (if you know it)

Current weight or BMI (if you know it)

Do you have a family history of osteoporosis?

Yes

No

Not sure

Have you had any fractures from a minor injury or fall? *

Yes

No

Have you had a DEXA scan (bone density scan)? *

Yes

No

Not sure

Are you taking calcium or vitamin D supplements? *

Yes

No

Have you used HRT before? *

Yes

No

Not sure

Please list all current medications you take *

Include doses and frequency if you know them

Are you currently taking SSRIs or other antidepressants? *

Yes

No

Do you smoke?

Yes

No

Former smoker

How many units of alcohol do you drink per week?

1 unit = small glass of wine, half pint of beer, or single spirit

How often do you exercise and what type?

For example: 3 times per week, 30 minutes of brisk walking

Have you noticed weight changes since your menopause symptoms started?

Include amount and direction (gain/loss) and over what period

What are you hoping for from this consultation? *

HRT - I want to start

Non-HRT symptom relief

Second opinion on my current HRT

HRT dose adjustment

General menopause advice

Help with specific symptom

Bone health assessment

Other

Is there anything else you'd like us to know before your appointment?

Here's what you've told us. Have a quick check, then hit send - this means your consultation can focus on what actually matters to you.

Your details

Name

Email

Phone

Date of birth

Menopausal Status

What is your current menstrual status? -

Menopausal Symptoms - Greene Climacteric Scale

Hot flushes -

Sweating episodes -

Night sweats -

Heart beating quickly or strongly / palpitations -

Feeling tense or nervous -

Difficulty sleeping -

Feeling excitable -

Panic attacks -

Feeling tired or lacking energy -

Difficulty concentrating -

Loss of interest in things -

Feeling unhappy or depressed -

Crying spells -

Irritability -

Feeling dizzy or faint -

Pressure or tightness in head -

Parts of body feel numb or tingling -

Headaches -

Muscle or joint pains -

Loss of feeling in hands or feet -

Loss of interest in sex -

Vaginal dryness -

Symptom Deep Dive

Which symptoms bother you most? -

HRT Safety Screening

Have you ever had a blood clot (DVT - in leg) or pulmonary embolism (PE - in lungs)? -

Have you or a close family member had breast cancer? -

Have you had a stroke or heart attack? -

Do you have migraine with aura (flashing lights or visual disturbances before headache)? -

Have you had liver disease? -

Do you have any unexplained vaginal bleeding? -

Current blood pressure (if you know it) -

Current weight or BMI (if you know it) -

Bone Health

Do you have a family history of osteoporosis? -

Have you had any fractures from a minor injury or fall? -

Have you had a DEXA scan (bone density scan)? -

Are you taking calcium or vitamin D supplements? -

Previous HRT Experience

Have you used HRT before? -

Current Medications

Please list all current medications you take -

Are you currently taking SSRIs or other antidepressants? -

Lifestyle

Do you smoke? -

How many units of alcohol do you drink per week? -

How often do you exercise and what type? -

Have you noticed weight changes since your menopause symptoms started? -

Your Goals

What are you hoping for from this consultation? -

Is there anything else you'd like us to know before your appointment? -

Anything else for your doctor?