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Stonehill Medical Centre

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Appointments
Prescriptions
Test Results
Patient Record
Health Advice
Online Forms
Services

Home
Language
Opening Hours
News
Online Services
Practice Staff
Contact Us

Menopause Symptom Form

Please complete as much of this form as you can.

Once complete, a member of our reception team will contact you to book an appointment.

Thank you

Last Updated: 28/02/2024

Your Details

Name *

Date of Birth *

Contact telephone number

Height

Weight

Blood pressure reading

VASOMOTOR SYMPTOMS

Heart beating quickly or stronly

Infrequent

Everyday

1-2 times per week

3-4 times a week

Difficulty sleeping

Infrequent

1-2 times per week

3-4 times a week

Everyday

Feeling Tired or Lack of Energy

Infrequent

1-2 times a week

3-4 times a week

Everyday

Feeling Dizzy or Faint

Infrequent

1-2 times a week

3-4 times a week

Every day

Hot Flushes

Infrequent

1-2 times a week

3-4 times a week

Everyday

Sweating at night

Infrequent

1-2 times a week

3-4 times a week

Everyday

Physical Symptoms

Pressure or tightness in head or body

Infrequent

1-2 times a week

3-4 times a week

Everyday

Ringing in ears

Infrequent

1-2 times a week

3-4 times a week

Everyday

Headaches

Infrequent

1-2 times a week

3-4 times a week

Everyday

Muscle or Joint pain

Infrequent

1-2 times a week

3-4 times a week

Everyday

Pins & Needles in any part of the body

Infrequent

1-2 times a week

3-4 times a week

Everyday

Psychological Symptoms

Feeling Tense or Nervous

Infrequent

1-2 times a week

3-4 times a week

Everyday

Memory Issues

Infrequent

1 - 2 times a week

3-4 times a week

Everyday

Panic attacks or anxiety

Infrequent

1-2 times a week

3-4 times a week

Everyday

Crying Spells

Infrequent

1-2 times a week

3-4 times a week

Everyday

Loss of interest in most things

Infrequent

1-2 times a week

3-4 times a week

Everyday

Irritablility

Infrequent

1-2 times a week

3-4 time a week

Everyday

Urogenital Symptoms

Loss of interest in sex

Infrequent

1-2 times a week

3-4 times a week

Everyday

Vaginal Dryness

Infrequent

1-2 times a week

3-4 times a week

Everyday

Urinary Symptoms

Infrequent

1-2 times a week

3-4 times a week

Everyday

Medical History

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

Any other questions

Do you have anything else you would like to add?

Thank you for completing the questionnaire. A member of our reception team will contact you to book an appointment with a GP. Thank you

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