Menopause Symptom Questionnaire

If you haven’t already, you can read our information page about the menopause on our main website – Menopause – Bruntsfield Medical Practice

Menopause Symptom Questionnaire

Please use this questionnaire to record any symptoms you may be experiencing for further discussion with your health professional.
Please put the score (0 – 5) that best describes your symptoms in the ‘your score’ column.


1. Psychological and Emotional symptoms: Over the past 3 months have you noticed any changes in your mood, being more irritable or anxious, changes to your confidence or memory?
2. Vulva/vaginal symptoms: 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?
3. Urinary symptoms: Has there been a change in the way you urinate (pass water) to more frequent or more urgently?
4. Symptoms around sex: Has intercourse (having sex) or smear tests been more painful or caused any bleeding?
5. Physiological Symptoms: 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.
6. Bleeding or Period symptoms: Have you experienced changes to your bleeding pattern with spotting, irregular, heavy or missed periods.
From your answers you can calculate your total menopause symptom score: (0–6 mild, 7–18 moderate, 19–30 severe symptoms)

These symptoms are affecting my:

Ability to work
Enjoyment of life

Your needs:

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