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BUCKINGHAMSHIRE MEDICAL

Care you need, when you need it

Menopause
Medical Questionnaire

Complete our questionnaire if you would like to begin Hormone Replacement Therapy

First name

Last name

Date of Birth

Select an Address

Phone

Date of your last menstrual period:

Frequency of menstrual cycles over the past year:

Any recent changes in menstrual cycle pattern (e.g., irregular periods, skipped periods, heavy periods)?

Are you currently sexually active?

Are you currently using any contraception (e.g. pill, implant, injection, coil)?

What was the result of your last cervical smear test?

Have you experienced any of the following symptoms? (Tick all that apply)

Hot flashes/night sweats

Brain fog

Fatigue

Difficulty sleeping

Vaginal dryness

Mood swings

Changes to sex drive

Urinary symptoms (e.g.

Joint pains/aches

Other symptoms

Do you have any medical conditions (e.g. hypertension, diabetes):

Is there any surgical history related to reproductive organs (e.g. hysterectomy, oophorectomy)?

Is there any personal or family history of the following? (Tick all that apply)

Breast cancer

Ovarian cancer

Blood clots (e.g. pulmonary embolisms

Unexplained vaginal bleeding

Bleeding disorders

Liver disease

Please list any regular medications you take

Please list any allergies to medicines or other substances

What is your height?

What is your weight?

What was your last blood pressure reading? When was it done?

Do you smoke?

Do you drink any alcohol? If yes, how many units per week?

If you have had any recent blood tests/ scans please provide details/results here

Any additional comments?

Please provide the name and address of your registered GP practice

Please read the following, and confirm that you understand and agree

I declare that the information I’ve provided is accurate and complete, and that this medicaton is for my personal use only.

I have read, understood and agree to Buckinghamshire Medical's Terms & Conditions View Terms & Conditions

Thank you! Our Doctors will review the information and will contact you within 24 hours

BUCKINGHAMSHIRE MEDICAL