Cervical Screening

Cervical screening (smear test) is a quick test to check your cervix (neck of the womb) for the Human Papilloma Virus (HPV). HPV is a common virus that can cause

Menopause Symptoms Questionnaire

Please complete this questionnaire if asked to do so by a member of our team to record any symptoms you may be experiencing for further discussion with your health professional. 

Menopause Symptom Questionnaire
Please use format day/month/year e.g. 12/05/1979

What best describes your symptoms?

Over the past 3 months have you noticed any changes in your mood, being more irritable or anxious, changes to your confidence or memory?
Over the last 6 months, have you experienced any irritation, dryness or soreness or discharge in the vulva (outside part of female genitals) or vagina?
Has there been a change in the way you urinate (pass water) to more frequent or more urgently?
Has intercourse (having sex) or smear tests been more painful or caused any bleeding?
Have you experienced any of the following symptoms in the last 3 months: Palpitations- or your heart racing fast, sweats, flushing, night sweats, unable to sleep, headaches joint pains, tiredness or stomach bloating?
Have you experienced changes to your bleeding pattern with spotting, irregular, heavy or missed periods?
Automatically calculated.

Menopause Symptom Score:
(0–6 mild, 7–18 moderate, 19–30 severe symptoms)

How are the symptoms affecting you?

Ability to work?
Relationships?
Enjoyment of Life?

Height and Weight

Weight

Please provide details of your heigh and weight in either Metric or Imperial units.
Unit of measurement *
Choose your preferred unit of measurement.
cm
kg
ft
in
lbs

BMI

Underweight
Healthy
Overweight
Obese

Smoking Status

Do you smoke?
How many cigarettes do you smoke a day?
Would you like help to quit smoking?
Do use an e-Cigarette

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Please visit NHS Inform or see Menopause Matters for an overview of the menopause and support managing your symptoms.