Menopause Symptom Form

Have you had a hysterectomy? *

Yes No

Date of last menstrual period *

How often do you have periods and how long do they last?

Are you on any current contraception? If Yes, which contraception?

Do you smoke

Do you drink alcohol? If so how much?

Do you suffer from migraines? If so, how often

Have you ever had a DVT (Deep Vein Thrombosis)?

Yes No

Do you have high blood pressure or heart problems?

Yes No

Do you have a family history of breast or ovarian cancer

Yes No

Do you use any complementary medicines such as St. John's Wart?

Do you currently take any vitamin D Supplements?

Yes No

Further Information