🟣 Menopause Symptoms Assessment FormPlease complete this confidential assessment to help us understand your health and provide the best care possible tailored to you.Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone Number *Date of Birth *Are you currently having menstrual periods? *Yes, regularlyyes but irregularlyNo, they have stoppedAge of Menarche (First period)? your illnesses Age of final period? Age at birth of first child?Number of Children State any allergies that you haveList all family history of medical illnesses Do you have a personal history of breast cancer? *Any previous history of surgery including hysterectomy? *When was your last Pap Smear?When was your last Mammogram?When was your last Colonoscopy?When was you last Bone DXA?When was your last executive profile?If yes, have you noticed any recent changes?Heavier PeriodsLighter PeriodsSkipping PeriodsMore Frequent PeriodsNo ChangesHave you taken hormonal birth control? *YesNoNot SureHave you taken hormone replacement therapy (HRT) ? *YesNoNot SurePlease check the box for any of the following symptoms you may be experiencing:Understanding my symptomsHot flashesnight sweatsPalpitationsTrouble sleepingBrain fog (mental fogginess, inability to concentrate, memory lapses)IrritabilityAnxietyDepressionMood variabilityLow energy / FatigueVaginal drynessPainful sexFrequent urinationBurning with urinationIncontinenceLow libidoWeight gainMuscle and joint painsSkin & hair changesOverall, how much are these symptoms impacting your daily life?Mild- Noticeable but manageableModerate- Affecting Daily ComfortSevere-significantly impacting my quality of lifeDo you have any of the following? (Optional)HypertensionDiabetesThyroid ConditionsCardiac DiseaseHypercholesterolemiaAutoimmune DiseaseNoneHow would you describe your stress levels *LowModerateHighDo you partake in the following? Select the boxes that apply *SmokingDrink AlcoholDrink CaffeineExerciseGoals for Visit — What would you like help with today? (copy) *Understanding my symptoms and the menopausal transitionMidlife Health OptimizationManagement of symptomsHormonal therapy counselling and initiationSubmit
