Menopause Symptom Questionnaire - Medi Gyn

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Hormone Balancing Questionnaire - Part 2

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Speak with our Hormone Specialist within 24 hours. Available online across Dubai, Saudi, Qatar, Oman & Kuwait.

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Full Name

Telephone

Email Address

Address

How did you hear about us?

What do you expect from BHRT?

DOB

Current Age

Nationality

No. of Children

Weight/Height/BMI

Blood Pressure (reading if known)

Date of your last Menstruation

What current contraception are you on? If none, please state none

Are you on any hormone therapy right now? If so please specify

Do you have a mirena coil? Please include date inserted or state none

Do you have any family history of following medical conditions? Please select the right answer for you

Diabetes

Yes No

High Blood Pressure

Yes No

Heart Disease

Yes No

Autoimmune Disease

Yes No

Skin Disease

Yes No

Allergies

Yes No

High Cholesterol

Yes No

Breathing Difficulty

Yes No

Cancer

Yes No

Clots in the blood/ deep vein thrombosis

Yes No

How much you are troubled by any of these symptoms at present? Please specify

Heart beating quickly or strongly

Rare Mild Frequent Severe

Feeling tense or nervous

Rare Mild Frequent Severe

Difficulty in sleeping

Rare Mild Frequent Severe

Being/ feeling hyperactive

Rare Mild Frequent Severe

Memory problems

Rare Mild Frequent Severe

Attacks of panic or anxiety

Rare Mild Frequent Severe

Difficulty in concentrating

Rare Mild Frequent Severe

Feeling tired or lack of energy

Rare Mild Frequent Severe

Loss of interest in most things

Rare Mild Frequent Severe

Feeling unhappy or depressed

Rare Mild Frequent Severe

Crying spells

Rare Mild Frequent Severe

Irritability

Rare Mild Frequent Severe

Feeling dizzy or faint

Rare Mild Frequent Severe

Pressure or tightness in head or body

Rare Mild Frequent Severe

Tinnitus (ringing or buzzing in ears)

Rare Mild Frequent Severe

Headaches

Rare Mild Frequent Severe

Muscle or joint pains

Rare Mild Frequent Severe

Pins and needles in any part of the body

Rare Mild Frequent Severe

Hot flushes

Rare Mild Frequent Severe

Night sweats

Rare Mild Frequent Severe

Loss of interest in sex/ loss of libido

Rare Mild Frequent Severe

Vaginal dryness

Rare Mild Frequent Severe

Urinary symptoms

Rare Mild Frequent Severe

Any history in the past? Please say yes or no

Diabetes

Yes No

High Blood Pressure

Yes No

Heart Disease

Yes No

Autoimmune Disease

Yes No

Skin Disease

Yes No

Allergies

Yes No

High Cholesterol

Yes No

Breathing Difficulty

Yes No

Cancer

Yes No

Clots in the blood/ deep vein thrombosis

Yes No

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

Do you suffer from the following? If yes, please specify

Bloating

Yes No

Tiredness

Yes No

Irritability

Yes No

Breast Tenderness

Yes No

Headaches

Yes No

Depression

Yes No

Aching joints

Yes No

Hot flushes/ Night sweats

Yes No

Dry skin

Yes No

Weight-gain/ Weight-loss

Yes No

Cold feet & hands

Yes No

Brain fog

Yes No

Poor memory

Yes No

Constant forgetfulness

Yes No

Urinary needs/ incontinence

Yes No

Mood swings

Yes No

Stress

Yes No

Any other bodily change/s

Yes No

Have you had any gynaecological or any other surgeries in the past eg. Hysterectomy (total or subtotal) etc.? Please specify

Lifestyle & Eating Habits

Breakfast/ Lunch/ Dinner

Yes No

Are you vegetarian/ vegan?

Vegetarian Vegan

How much water do you drink? Please specify amount per day?

Do you drink any other stimulates ie. Coffees, teas, energy drinks etc.?

Do you smoke? If so, how often, how many cigarettes of grams of tobacco if rolls

What are your sleeping habits? Please describe

Do you take any substances ie. Hard drugs?

How much alcohol intake I.E. Units weekly?

Supplements intake: what kinds, brands?

Sports: types/ how often?

MEDITATION/ BREATHWORK?

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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