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Tel: 021 4305544/021 4391866
Fax: 021 4399675
MENOPAUSE

Menopause

First Menopause Consultation Questionnaire

* Indicates required field

Patient Name: *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth: *

Please outline the main problems you would like to discuss at this meeting: *

A few quick questions that will help assess your suitability for HRT if you are interested in this:

Have you ever had (Check all that apply): *

Breast Cancer Ovarian Cancer Womb Cancer High Blood Pressure High Blood Pressure in Pregnancy High Blood Pressure on the Pill A Blood Clot A Blood Clot in Pregnancy A Blood Clot on the Pill

Check all that apply

Has anyone in your immediate family had: *

Breast Cancer Blood Clots

Check all that apply

Do you smoke? *

Yes No

If your periods have stopped how long ago did they stop? *

Thank you for completing this form, don't forget to schedule your First Menopause consultation! You can book here:

Submit

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OR CALL TO BOOK: 021 4305544 / 021 4391866

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Home
Forms
Websites & Links
Contact Us
Tel: 021 4305544/021 4391866
Fax: 021 4399675
MENOPAUSE

Menopause

First Menopause Consultation Questionnaire

​A few quick questions that will help assess your suitability for HRT if you are interested in this: