START YOUR PERIMENOPAUSE QUESTIONNAIRE


1. How regular are your periods:




* If you have a hormone contraceptive implant, it may lead to you having no periods for a long duration that maybe confused for menopause

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



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



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):

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

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

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

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

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

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


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.