Free Menopausal Health Assessment

Name *

First

Last

Email *

By submitting your email address you agree to receive emails from WellFemme.

What is your age?

45 or less
46 or older

Have you had a hysterectomy? (Your uterus removed)

Yes
No

Have you had your ovaries removed or had treatment that stopped them from working eg. chemotherapy?

Yes
No

When was your last menstrual period?

More than 12months ago
Less than 12months ago
Unsure- I have a Mirena IUD or other medication or surgery that stopped my period

Was it more than 10 years ago?

Yes
No

Have you ever had breast cancer?

Yes
No

Do you have osteoporosis?

Yes
No

Do you have any of these osteoporosis risk factors? -Poor dietary calcium intake? eg. dairy food
-A history of bone fracture from quite a small impact?
-Several years or more without periods?
-Used steroid medications for more than 3 months?
-Rheumatoid arthritis
-Thyroid or parathyroid disorders?
-Coeliac or malabsorption disease?
-A strong family history of osteoporosis?
-Low body weight? eg. BMI less than 20

Do you have any of these osteoporosis risk factors?

Yes
No

Hot flushes and/or night sweats

none
mild
moderate
severe

Mood changes, eg. new or worsening anxiety, depression and/or irritability

none
mild
moderate
severe

Sleep disturbance

none
mild
moderate
severe

Vaginal dryness and/or pain

none
mild
moderate
severe

Urinary frequency, urgency or UTIs

none
mild
moderate
severe

Do you have any of these heart disease risk factors? -More than 10kg overweight, or waist measurement over 80cm?
-Smoker?
-High blood pressure, or medication for high blood pressure?
-High cholesterol, or medication for high cholesterol?
-Diabetes?
-Family history of heart disease, strokes or diabetes

Do you have any of these heart disease risk factors?

Yes
No

Do you have any of the following breast or vaginal issues: -Breast pain, lumps or discharge?
-Strong family history of breast, ovarian or bowel cancer?
-Heavy or unusual vaginal bleeding?
-New vaginal bleeding after more than 12months of no periods?
-Unusual vaginal discharge?
-Pelvic or vaginal pain?

Do you have any of the following breast or vaginal issues:

Yes
No

Do you have any of these conditions? -Uncontrolled high blood pressure? (above 140/90)
-A condition which makes your blood clot too much?
-A history of blood clots or stroke?
-Heart disease or angina?
-Migraine headaches?
-A diagnosis of heart disease?
-Lupus (SLE)?
-Liver problems?

Do you have any of these conditions?

Yes
No

Thank you for using WellFemme’s Menopause Assessment Tool. After submitting your answers you will receive an on-screen and emailed report.

WellFemme’s Menopausal Health Assessment

wellfemme

Regular GP

Has this patient ever had: