Dorema Surgery

Menopause Symptom Questionnaire

Your doctor may ask you to fill out the below questionnaire prior to an appointment to get a better idea of the symptoms you are experiencing. This will allow them to tailor any treatment offered to your needs.

Please also consider having a read of the Menopause Matters website prior to your appointment.

Please make sure you arrange an appointment to discuss your symptoms once you’ve completed the form as doing the questionnaire won’t automatically generate a response from the surgery.

Menopause Symptom Questionnaire

For confidentiality please only enter your first and last initials
In the format DD/MM/YYYY
Psychological and Emotional Symptoms(Required)
Over the past 3 months have you noticed any changes in your mood, being more irritable or anxious, changes to your confidence or memory?
Vulva/vaginal symptoms(Required)
Over the last 6 months, have you experienced any irritation, dryness or soreness or discharge in the vulva (outside part of female genitals) or vagina?
Urinary symptoms(Required)
Has there been a change in the way you urinate (pass water) to more frequent or more urgently?
Symptoms around sex(Required)
Has intercourse (having sex) or smear tests been more painful or caused any bleeding?
Physiological Symptoms(Required)
Have you experienced any of the following symptoms in the last 3 months: Palpitations- or your heart racing fast, sweats, flushing, night sweats, unable to sleep, headaches joint pains, tiredness or stomach bloating
Bleeding or Period symptoms(Required)
Have you experienced changes to your bleeding pattern with spotting, irregular, heavy or missed periods
The above symptoms are affecting my ability to work
The above symptoms are affecting my relationships
The above symptoms are affecting my enjoyment of life
Please provide a recent weight
Please provide your height

Date published: 21st March, 2023
Date last updated: 21st March, 2023