Questionnaire

Personal Details

Name(Required)

First Last

Date of Birth(Required)

Sex(Required)

Ethnicity(Required)

Height(Required)

Weight(Required)

Email address(Required)

When was your last period(Required)

More than a year ago

Less that a year ago

I am still having periods

Are you sexually active?(Required)

Yes

No

Are you using contraception?

Do you ever experience any heavy bleeding?(Required)

Yes

No

Do you ever experience any painful bleeding?(Required)

Yes

No

Have you ever been diagnosed with Endometriosis or Adenomyosis?(Required)

Yes

No

Have you had a hysterectomy? (Removal of womb/uterus)(Required)

Yes

No

Please give more details below

Are you up to date with smear tests?(Required)

Yes

No

Have you ever had an abnormal result(Required)

Yes

No

Have you ever been diagnosed with cancer?(Required)

Yes

No

Please give more details below

Have you ever had a blood clot in your leg (Deep Vein Thrombosis) or a blood clot in your lungs (Pulmonary Embolism)(Required)

Yes

No

Do you have any family history of breast cancer or ovarian cancer?(Required)

Yes

No

If possible please outline this history below including age of family members

Have you had a mammogram?(Required)

Yes

No

What was the result? Please give more information below

Have you had a bone scan?(Required)

Yes

No

Please give more information below

Are you taking any regular medication?(Required)

Yes

No

Please document the medication that you re taking including over the counter medication

Are you taking HRT(Required)

Yes

No

Please include name of HRT below

What questions would you like answered today?(Required)

Lifestyle tips to help manage menopausal symptoms

Information about HRT

Advice about bone health

Testosterone advice

HRT and breast cancer risk

Other

Please enter your question(s)

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