The Really Useful Health Company
162 Warren Rd, Brighton BN2 6DD
(01273) 609699
07460 684409
Email:
MENOPAUSE QUESTIONNAIRE
A. NAME ______Age ______Date ______
ADDRESS ______
Postcode ______Tel. No ______Work Tel. No ______
Email: ______
Please complete all the questions on this form to the best of your ability. The information you provide will enable us to give you the best service we possibly can. The information you give will be respected and used only by us for your benefit
STRICT CONFIDENTIALITY WILL BE OBSERVED
B.MARITAL STATUS
Single ______Married ______Divorced ______Separated ______Widowed ______
Height ______ft ______ins Average weight ______st ______lbs Average waist measurement ______Hip measurement ______
C. CONTRACEPTION
Are you still using contraception? Yes/No If yes, please give details ______
Have you ever taken Oral Contraceptives? Yes ______No ______
If so, did you notice any side effects when on off the Pill? Yes ______No ______or coming off the pill?
Yes ______No ______
Have you taken oral contraceptives in the last twelve months? Yes ______No ______
D.PERIODS (delete as applicable)
How frequent were/are your periods? ______How long did/do your periods last for? ______
Your periods were/are light _____ moderate ____ heavy______How long ago was your last period? ______
E.PREGNANCIES
Please answer the following carefully. How many:-
Pregnancies have you had? ___ Miscarriages/abortions have you had? _ Successful pregnancies have you had? ___
Current ages and birth weight of your children
1st child age ______weight _____lbs ____ oz 2nd child age ______weight ______lbs _____oz
3rd child age ______weight _____lbs _____ oz 4th child age ______weight ______lbs _____ oz
Did you breastfeed if so, for how many months in total? ______months
F. SOCIAL CIRCUMSTANCES
Do you work as a housewife? Full time ______Part time ______Not at all ______
Do you have an occupation (as well)? Yes ______No ______
If so, what is it? ______Do you work: Full-time ____ Part-time _____
Do you have a regular sexual partner? Yes _____ No _____ Do you live together? Yes ______No ______
G. CURRENT USE OF VITAMINS / DRUGS etc.
Are you currently taking: (Please state dosage and brand)
Vitamins______
Minerals ______
Other natural products______
Are you currently taking Hormone Replacement Therapy? Yes ____ No____ Pill/Patch/Implant ______
Have you had any side effects to HRT ? (if yes please give details) ______
For how long did you take HRT? __ months ___ years
Did you stop HRT because of side effects or dissatisfaction? Yes _____ No ______
Which of the above have you taken for the menopause?______
H.ARE YOU CURRENTLY UNDER MEDICAL TREATMENT? Yes ______No ______
Details please ______
Have you had any previous treatment for the menopause? Yes ______No ______
If yes, what was it and was it of any help? Give details ______
______
I.CURRENT SYMPTOMS Do you suffer from any of the following. Please ensure symptom is only ticked once.
* How many times per month / NONE / MILD / MODERATE / SEVERE1. Hot/Cold flushes *
2. Facial/Body flushing *
3. Night sweats *
4. Palpitations *
5. Panic attacks *
6. Generalised aches and pains
7. Depression
8. Perspiration
9. Numbness/skin tingling in arms and legs
10. Headaches
11. Backaches
12. Fatigue
13. Irritability
14. Anxiety
15. Nervousness
16. Loss of confidence
17. Insomnia
18. Giddiness/Dizziness
19. Difficulty/frequency in passing water
20. Water retention
21. Bloated abdomen
22. Constipation
23. Itchy vagina
24. Dry vagina
25. Painful intercourse
26. Decreased sex drive
27. Loss of concentration
28. Confusion/Loss of vitality
Are any of the above symptoms cyclic? (i.e come in cycles, for example on a monthly basis) ______
______
J.Have you noticed since the onset of the menopause? 1. Loss of height: Yes/No If yes, how much ______
2. Difficulty in bending: Yes/No
3. Increased curvature of back: Yes/No
K.Have you gained weight since you started the menopause? Yes /No If yes, how much ______
Do you have any other menopausal symptoms not mentioned above? ______
Did you suffer from pre-menstrual tension prior to the menopause? Yes /No If yes, for how long? ______
If yes, were your symptoms mild ______moderate ______severe ______
L. RECENT MEDICAL HISTORY Please answer the following question carefully. Do you have any of the following complaints or have you suffered from them in the last 5 years? Yes No
1. Infertility
2. Epilepsy
3. Eczema
4. Asthma
5. Hayfever
6. Nettle rash/Urticaria
7. Migraine
8. Depression
9. More than one mouth ulcer per year
10. More than 2 episodes of cystitis in the last 5 years
11. Herpes - cold sore face/mouth
12. Herpes - genital or vaginal
13. More than 2 episodes of thrush in the last 5 years
14. Anaemia
15. Breast disease /problems (not cancer)
1.______
2.______
3.______4.______
5.______
6.______7.______8.______9.______10.______11.______12.______
13.______14.______
15.______
Which of the above, if any, is a particular problem to you at present ______
M.MEDICAL HISTORY Have you ever had:
Yes / No1. Diabetes
2. Thyroid disease
3. Other hormonal problems
4. Breast cancer
5. Cancer of the cervix of the womb
6. Ovarian Cysts
7. Endometriosis
8. Cancer other than above
9. Any Gynaecological operations
Give details of the above and which of these, if any, do you have at present ______
______
N.CURRENT HEALTH STATE
Do you suffer from:YesNo
1. Diarrhoea 1. ______
2. Constipation 2.______
3. Excessive wind 3.______
4. Itchy bottom 4.______
5. Acne 5.______
6. Greasy facial skin 6.______
7. White spots on nails 7.______
8. Split brittle nails 8.______
9. Sore tongue 9.______
10. Cracking at corners of the mouth10.______
11. Poor hair growth11.______
12. Dandruff12.______
13. Dry/ Rough red pimply skin on your upper arms or thighs13.______
Which of these, if any, is a problem to you now______
O.
oo Since the onset of the Menopause: Mildly Moderately GreatlyHas the condition of your skin deteriorated?
Has the condition and texture of your hair altered?
Has the condition of your nails been affected?
P. DIETARY QUESTIONNAIRE
1. IN A DAY How many cups/mugs do you drink of:Tea ______Coffee ______
2. How many teaspoons of sugar do you add to yourTea ______Coffee ______
3. On average how many cigarettes do you smoke per day ______
4. On average how many ‘units’ of alcohol do you consume per day ______
(1 unit = 1 glass of wine = 1/2 pint of beer/lager = 1 spirit = 1 sherry/vermouth)
Answer the following question carefully. Tick one
5. Are you either: a VEGAN (eating only vegetable produce) ______a VEGETARIAN (eating anything except meat, poultry or fish) ______or an OMNIVORE (eating anything including some meat, poultry and fish) ______
IN A WEEK How many servings/portions do you have of:
Green vegetables ______Salads ______Red meat ______Fruit ______
Cake/Biscuits ______( 1 portion = 1cake = 3 biscuits) Chocolate ______Puddings/Ice-cream/Sweet pies ____
Soft drinks ______(not low calorie) 1 can = 1 portion Chocolate based food/drinks ___ Cola based drinks ____
IN A DAY How many of the following foods would you normally eat:
Bread: Slices of: Wholemeal (not brown bread) __ White or brown (not wholemeal) __ Bran, bran based cereal, muesli ___
Portions of dairy products ( 1 portion = 4 oz milk = 4 oz yoghurt (1 serving) = 2 oz cheese
Milk ______Yoghurt ______Cheese ______Butter ______Other animal fat ______
Do you add salt to your cooking? Yes _____ No ____ Do you add salt to your food at the table? Yes ___ No __
Q.CRAVINGS At any time of the month do you crave any of the following foods:
Chocolate Yes ____ No _____ Sweets Yes _____ No _____ Alcohol Yes _____ No ______
Savoury foods Yes _____ No _____ Other foods Yes _____ No ______Give details ______
R.EXERCISE
How many times a week and for how long do you do an areobic exercise. (i.e one that increases your heart rate)
e.g. swimming, cycling, running ______
S.BEHAVIOUR AND SOCIAL ACTIVITIES
1. For how long have you had significant menopausal symptoms? Years ______months ______
Do you consider that the menopausal symptoms have adversely affected the following, if yes score as follows.
2. Your home life/relationships with family/friendsYes ____ No ____ 1 ____ 2 ____ 3 _____
3. Your work/career (leave blank if working as a housewife full time)Yes ____ No ____ 1 ____ 2 ____ 3 _____
4. Your relationship with your sexual partnerYes ____ No ____ 1 ____ 2 ____ 3 _____
HAVE YOU EVER
5. Contemplated suicide whilst suffering from the MenopauseYes ______No ______
If yes, how many timesOnce ___ more than once ___ more than 6 times ____
6. Been violent/aggressive towards others whilst suffering from the Menopause Yes ______No ______
If yes, how many timesOnce ____ more than once ____ more than 6 times ___
7. What is the worst problem the menopause has created for you ______
______
T. 1. Do you drive a car?Yes ______No ______
2. Do you consider your driving ability is affected by your symptoms. Increased/decreased/the same
3. How do you consider your work efficiency/productivity is affected Increased/decreased/the same
by the menopause. If decreased by how many days?1-2 _____2-3 ______3-4 ______More ______
4. Do you think that other people, family, friends and work associates are
aware of a change in your behaviour when you are suffering?Yes ____ No ____ Give details
______
5. Since being menopausal has your frequency of sexual intercourse: Increased/decreased/the same
If decreased, please score as above1 ______2 ______3 ______
6. Since being menopausal has your enjoyment of sexual intercourse:Increased/decreased/the same
If decreased, please score as above1 ______2 ______3 ______
- WHAT ARE YOUR WORST MENOPAUSE SYMPTOMS?
HOW DID YOU HEAR ABOUT THE REALLY USEFUL HEALTH COMPANY?
______
WHAT PROMPTED YOUR DECISION TO USE THE REALLY USEFUL HEALTH COMPANY?
______
IS THERE ANYTHING ELSE YOU WOULD LIKE TO MENTION?
Thank you for completing this questionnaire
Copyright N.H.A.S. September 2007