WHS FORMS

1. MODIFIED GREENE SCALE

* Indicates required field

Name *

First

Last

DATE OF BIRTH *

1. Hot flushes *

2. LIGHT HEADED FEELINGS *

3. HEADACHES *

4. IRRITABILITY *

5. DEPRESSION *

6. UNLOVED FEELINGS *

7. ANXIETY *

8. MOOD CHANGES *

9. SLEEPLESSNESS *

10. UNUSUAL TIREDNESS *

11. BACKACHE *

12. JOINT PAINS *

13. MUSCLE PAINS *

14. NEW FACIAL HAIR *

15. DRY SKIN *

16. CRAWLING FEELINGS UNDER SKIN *

17. LESS SEXUAL FEELINGS *

18. DRY VAGINA *

19. UNCOMFORTABLE INTERCOURSE *

20. URINARY FREQUENCY *

SCORE (Completed by Nurse) *

TOTAL SCORE (Completed by Nurse) *

Submit

2. FIRST MENOPAUSE CONSULTATION QUESTIONNAIRE

* Indicates required field

Name *

First

Last

ADDRESS *

AGE *

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?:

BREAST CANCER *

OVARIAN CANCER *

WOMB CANCER *

BOWEL CANCER *

HIGH BLOOD PRESSURE *

A BLOOD CLOT *

ANY PREGNANCIES *

IF 'YES' HOW MANY? *

A BLOOD CLOT IN PREGNANCY *

HIGH BLOOD PRESSURE IN PREGNANCY *

DIABETES IN PREGNANCY *

A BLOOD CLOT ON THE PILL *

ENDOMETRIOSIS *

LIVER PROBLEMS *

WHEN WAS YOUR LAST SMEAR? *

WHEN WAS YOUR LAST MAMMOGRAM? *

Has anyone in your immediate family had:

BREAST CANCER *

WOMB CANCER *

OVARIAN CANCER *

BLOOD CLOTS *

DO YOU SMOKE OR VAPE? *

How much alcohol to you drink per week? (IU - UNITS) *

What was the first day of your last period? *

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

Has your bleeding pattern changed? *

IF YES, HOW SO? *

Do you need (or are you using ) contraception at present? *

Please 'submit' this form and bring along a list of any prescribed medication you are taking to your First Menopause visit.

Submit

WOMEN'S HEALTH SCREENING FORMS

Before your consultation - please complete the three short forms below and submit them for Nurse Máire to review

1. MODIFIED GREENE SCALE

2. FIRST MENOPAUSE CONSULTATION QUESTIONNAIRE

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

3. Calcium intake (follow the link, then enter your score below)

WOMEN'S HEALTH SCREENING FORMS ​

Before your consultation - please complete the three short forms below and submit them for Nurse Máire to review ​

1. MODIFIED GREENE SCALE

2. FIRST MENOPAUSE CONSULTATION QUESTIONNAIRE

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

3. Calcium intake (follow the link, then enter your score below)

WOMEN'S HEALTH SCREENING FORMS

Before your consultation - please complete the three short forms below and submit them for Nurse Máire to review

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