Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone

(###)

###

####

When was your last period

MM

DD

YYYY

Are your periods Regular

Yes

No

Are your periods painful?

Yes

No

Are your periods Heavy?

Yes

No

Breast Cancer

Yes

No

Blood Clot in a Leg or a Lung

Yes

No

Stroke

Yes

No

Heart Disease

e.g Heart attack, stents, bypass,angina

Yes

No

Osteoporosis

Yes

No

Migraine

Yes

No

Breast Cancer

Yes

No

Blood Clot in leg or lung

Yes

No

Stroke

Yes

No

Heart Attack

Yes

No

Osteoporosis

Yes

No

Migraine

Yes

No

Do You smoke?

Yes

No

Ex-Smoker

Do You drink Alcohol?

Yes

No

Have you used HRT before

Yes

No

Have you had any difficulty taking any hormonal medications before e.g. contraception?

Yes

No

Please tick the box if you have noted any of the following symptoms recently.

Hot flushes / Sweats

Excess fatigue

Difficulty sleeping

Memory or concentration problems ‘Brain fog'

More aches/pains than usual

Difficulty losing/maintaining weight

Breast pains

Migraine/headaches

Chest pains or heart palpitations

Low mood/depression

Increased anxiety levels

Loss of interest in sex

Painful sex

Unexpected vaginal bleeding e.g. bleeding after sex

Vaginal dryness

Needing to pass urine more often or pain on passing urine

Have you tried any complementary/alternative therapies to help with your symptoms?

Yes

No

What therapies would you consider? Please tick all that apply.

Over-the-counter supplements

Prescribed hormonal replacement therapy (HRT)

Other non-hormonal prescribed medicines

Talking therapies