Menopause Symptom Questionnaire – Bruntsfield Medical Practice

Your Name *

Date of Birth *

Who is your menopause review appt with? *

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.

Symptoms:

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? *

0 - Not at all

1 - Rarely

2 - Less than half the time

3 - About half the time

4 - More than half the time

5 - Always

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? *

0 - Not at all

1 - Rarely

2 - Less than half the time

3 - About half the time

4 - More than half the time

5 - Always

3. Urinary symptoms: Has there been a change in the way you urinate (pass water) to more frequent or more urgently? *

0 - Not at all

1 - Rarely

2 - Less than half the time

3 - About half the time

4 - More than half the time

5 - Always

4. Symptoms around sex: Has intercourse (having sex) or smear tests been more painful or caused any bleeding? *

0 - Not at all

1 - Rarely

2 - Less than half the time

3 - About half the time

4 - More than half the time

5 - Always

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. *

0 - Not at all

1 - Rarely

2 - Less than half the time

3 - About half the time

4 - More than half the time

5 - Always

6. Bleeding or Period symptoms: Have you experienced changes to your bleeding pattern with spotting, irregular, heavy or missed periods. *

0 - Not at all

1 - Rarely

2 - Less than half the time

3 - About half the time

4 - More than half the time

5 - Always

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 *

0 - Never

1 - Rarely

2 - Sometimes

3 - Often

4 - Always

Relationships *

0 - Never

1 - Rarely

2 - Sometimes

3 - Often

4 - Always

Enjoyment of life *

0 - Never

1 - Rarely

2 - Sometimes

3 - Often

4 - Always

Your needs:

What is the most important thing you want to discuss? *

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.

Symptoms:

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:

Your needs:

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.