Menopause Symptom Questionnaire

If you have been advised by the practice, please use this form.

Menopause Symptom Questionnaire

Menopause Symptom Questionnaire

Patient Details

Please use this date format: DD/MM/YYYY.

Symptoms

Are you experiencing anxiety?
Do you have a low mood?
Are you experiencing depression?
Are you having mood swings?
Are you having crying spells?
Are you experiencing brain fog?
Do you have loss of confidence?
Are you experiencing poor concentration?
Are you experiencing poor memory?
Do you have a loss of joy?
Are you experiencing reduced self esteem?
Are you irritable?
Are you having heart palpitations?
Are you having difficulty sleeping?
Are you tired/lacking energy?
Are you getting headaches?
Do you have painful/aching joints?
Are you having hot flushes?
Do you get night sweats?
Have there been any changes to your periods?
Are you having vaginal symptoms?
Are you experiencing urinary symptoms?
Do you have a loss of libido?
Are you feeling dizzy/faint?
Do you have dry eyes/ears?
Have you had any changes in your oral health?
Is your hair thinning?
Do you have dry/itching skin (formication)?
Are you experiencing tinnitus?
Are you experiencing restless legs?
Have you noticed a change in body odour?
Have your allergies increased?
Are you experiencing digestive issues?