Perimenopause Form - Lancashire Gynaecologist

START YOUR PERIMENOPAUSE QUESTIONNAIRE

Name:

Email:

Mobile:

Age:

1. How regular are your periods:

They are still very regular

They are very irregular

I have not had a period for the last 12 months

2.Have you noticed any of these changes in the flow of your menstrual cycle recently?

Heavier flow

Lighter flow

No change

3. Have you noticed any changes in the duration of your periods:

Longer than usual

Shorter than usual

No change

4. Are you experiencing any of the following symptoms? Please indicate the severity for each symptom on a scale of 1 to 5 (1 being mild and 5 being severe):

i. Hot flashes or night sweats:

ii. Mood swings or irritability:

iii. Fatigue or low energy levels:

iv. Sleep disturbances (e.g., insomnia, restless sleep):

v. Vaginal dryness or discomfort during intercourse:

vi. Changes in libido (sex drive):

vii. Changes in skin elasticity or dryness:

viii. Other Pains:

Yes

5. Have you noticed any changes in your breast tissue?

Yes

6. Have you noticed any weight gain over the last 12 months

Yes

7. Have you noticed any hair thinning or hair loss?

Yes

8. Have you had any difficulties with memory or concentration recently?

Yes

Not Sure

9. Have you had any significant lifestyle changes recently? (e.g., changes in diet, exercise, stress levels)

Yes

10. Have you discussed your symptoms with a healthcare professional?

i. Yes, and I have received treatment or advice

ii. Yes, but I have not received treatment or advice yet

iii. No, I have not discussed my symptoms yet

When you submit this form, we will respond with information about our services and how we can be of assistance.
Please tick box if you would like us to update you about additional services that we think would be relevant to you.