Menopause Symptom Questionnaire - Tudor Lodge Surgery

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Phone:
01934 622665

Out of hours:
111

Email:

Bnssg.TLSenquiries@nhs.net

Location: 3 Nithsdale Road, Weston-super-Mare. BS23 4JP

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Menopause Symptom Questionnaire

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Menopause Symptom Questionnaire

Please note that we will not offer an appointment until we have received the below form.
Please also note our specialist nurses work on Monday and Tuesdays each week
(Sharon Hartmann and Mandy Garland).

Full Name

Date of Birth

Visits

Please tick the options below to show how much you are troubled at the moment by any of these symptoms.

Heart beating quickly or strongly

Not at all A little Quite a bit A lot / very much

Feeling tense or nervous

Not at all A little Quite a bit A lot / very much

Difficulty in sleeping

Not at all A little Quite a bit A lot / very much

Excitable

Not at all A little Quite a bit A lot / very much

Memory problems

Not at all A little Quite a bit A lot / very much

Attacks of panic or anxiety

Not at all A little Quite a bit A lot / very much

Difficulty in concentrating

Not at all A little Quite a bit A lot / very much

Feeling tired or lack of energy

Not at all A little Quite a bit A lot / very much

Loss of interest in most things

Not at all A little Quite a bit A lot / very much

Feeling unhappy or depressed

Not at all A little Quite a bit A lot / very much

Crying spells

Not at all A little Quite a bit A lot / very much

Irritability

Not at all A little Quite a bit A lot / very much

Feeling dizzy or faint

Not at all A little Quite a bit A lot / very much

Pressure or tightness in head or body

Not at all A little Quite a bit A lot / very much

Tinnitus (ringing or buzzing in ears)

Not at all A little Quite a bit A lot / very much

Headaches

Not at all A little Quite a bit A lot / very much

Muscle or joint pains

Not at all A little Quite a bit A lot / very much

Pins and needles in any part of the body

Not at all A little Quite a bit A lot / very much

Breathing difficulties

Not at all A little Quite a bit A lot / very much

Hot flushes

Not at all A little Quite a bit A lot / very much

Sweating at night

Not at all A little Quite a bit A lot / very much

Loss of interest in sex/loss of libido

Not at all A little Quite a bit A lot / very much

Vaginal dryness

Not at all A little Quite a bit A lot / very much

Urinary symptoms

Not at all A little Quite a bit A lot / very much

Date of last menstrual period

Your menstrual cycle (duration of bleeds, frequency between bleeds, any changes)?

Have you had any gynaecological surgery (at any time)?

Have you had a hysterectomy?

Yes No

What current contraception are you on? (if none, please state none).

Current HRT using

Do you have a Mirena coil? – please include date inserted

Smoking status (as much detail as possible eg how many cigarettes a day or grams of tobacco if roll ups)

Alcohol units (weekly)

Please describe your current diet

Migraine, DVT or Cardiovascular History including high blood pressure.

Any family history of breast or ovarian cancer (please state relative and age of relative)

Do you use any complimentary medicines (eg St John’s wort)?

Do you currently use Vitamin D supplement?

Your height

Your weight

Blood pressure reading

Please let us know your availability (Monday-Tuesday best times in the day)

Privacy policy

We may email you concerning your personal requests. We may process your personal data, which may be shared in anonymised form for research purposes. We do not email patients for marketing purposes or pass your personal details to third parties.

The Tudor Lodge Surgery is part of the Pier Health Group, a super partnership of GP practices working together to share knowledge, skills and resources.

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Opening Hours

Monday 08.00 – 18.30

Tuesday 08.00 – 18.30

Wednesday 08.00 – 18.30

Thursday 08.00 – 18.30

Friday 08.00 – 18.30

Saturday Closed

Sunday Closed

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3 Nithsdale Road, Weston-super-Mare. BS23 4JP

01934 622665

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