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Menopause Symptom Questionnaire

FULL NAME

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TELEPHONE

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EMAIL *

ADDRESS

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HOW DID YOU HEAR ABOUT US? 

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What do you expect from BHRT? 

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DOB

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CURRENT AGE *

NATIONALITY 

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NO OF CHILDREN

WEIGHT/ HEIGHT/ BMI 

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BLOOD PRESSURE (reading if known)

DATE OF YOUR LAST MENSTRUATION

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WHAT CURRENT CONTRACEPTION ARE YOU ON? If none, please state none

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ARE YOU ON ANY HORMONE THERAPY RIGHT NOW? If so please specify

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DO YOU HAVE A MIRENA COIL? Please include date inserted or state none
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DO YOU HAVE ANY FAMILY HISTORY OF following medical conditions? Please select the right answer for you

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Yes
No
Diabetes
High Blood Pressure
Heart Disease
Autoimmune Disease
Skin Disease
Allergies
High Cholesterol
Breathing Difficulty
Clots in the blood/ deep vein thrombosis
Cancer
HOW MUCH YOU ARE TROUBLED BY ANY OF THESE SYMPTOMS AT PRESENT? Please specify
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Rare
Mild
Frequent
Severe
Heart beating quickly or strongly
Feeling tense or nervous
Difficulty in sleeping
Being/ feeling hyperactive
Memory problems
Attacks of panic or anxiety
Difficulty in concentrating
Feeling tired or lack of energy
Loss of interest in most things
Feeling unhappy or depressed
Crying spells
Irritability
Feeling dizzy or faint
Pressure or tightness in head or body
Tinnitus (ringing or buzzing in ears)
Headaches
Muscle or joint pains
Pins and needles in any part of the body
Hot flushes
Night sweats
Loss of interest in sex/ loss of libido
Vaginal dryness
Urinary symptoms

ANY HISTORY IN THE PAST? Please say yes or no

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Yes
No
Diabetes
High Blood Pressure
Heart Disease
Autoimmune Disease
Skin Disease
Allergies
High Cholesterol
Breathing Difficulty
Clots in the blood/ deep vein thrombosis
Cancer

 

DO YOU HAVE ANY FAMILY HISTORY OF Diabetes,High Blood Pressure,Heart Disease,Autoimmune Disease,Skin Disease,Allergies,High Cholesterol,Breathing Difficulty,Clots in the blood/ deep vein thrombosis, cancer and what types? Please state a relative and age of relative if the answer is yes

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DO YOU SUFFER FROM THE FOLLOWING? If yes, please specify

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Yes
No
Bloating
Tiredness
Irritability
Breast Tenderness
Headaches
Depression
Aching joints
Hot flushes/ Night sweats
Dry skin
Weight-gain/ Weight-loss
Cold feet & hands
Brain fog
Poor memory
Constant forgetfulness
Urinary needs/ incontinence
Mood swings
Stress
Any other bodily change/s

HAVE YOU HAD ANY GYNAECOLOGICAL OR ANY OTHER SURGERIES IN THE PAST EG. HYSTERECTOMY (TOTAL OR SUBTOTAL) ETC.?

 Please specify

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LIFESTYLE & EATING HABITS

BREAKFAST/ LUNCH/ DINNER
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ARE YOU VEGETARIAN/ VEGAN? 

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HOW MUCH WATER DO YOU DRINK? Please specify amount per day

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DO YOU DRINK ANY other stimulates ie. coffees, teas, energy drinks etc.?

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DO YOU SMOKE? If so, how often, how many cigarettes of grams of tobacco if rolls

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WHAT ARE YOUR SLEEPING HABITS? Please describe

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DO YOU TAKE ANY SUBSTANCES ie. hard drugs?

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HOW MUCH ALCOHOL INTAKE i.e. units weekly?

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SUPPLEMENTS INTAKE: what kinds, brands?

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SPORTS: types/ how often?

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MEDITATION/ BREATHWORK?

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OTHER COMMENTS:

Please note that it is vital for us to receive your completed Menopause Symptom Questionnaire with any additional medical history information/ examination/ results you may wish to provide our medical team

m. +971 55 545 0797                                               e. info@medi-gyn.com

t. +971 4 566 2615                                                    ig. @medi_gyn_center

t. +971 52 200 5011                                                  w. www.medi-gyn.com

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