Menopause 45 years or older Menopause 45-60 Complete this form to tell us about symptoms you think may be due to the peri-menopause or menopause. This form follows the British Menopause Society Guidelines (BMS) and will be reviewed by a clinician to consider the diagnosis. As you are 45 years old or older, the diagnosis can be made on your symptoms alone. If the diagnosis is unclear then blood tests may be required. Once you have submitted the form, we will be in touch to discuss the next steps. This may involve blood tests, an appointment or our second form that advises you on your treatment options. Patient Details Patient Name * Date of Birth * Mobile number to contact you * Symptoms The peri-Menopause tends to come a few years before the Menopause. The hallmark of the peri-Menopause is irregular periods. Other symptoms may include: Hot flushes (A sudden feeling of heat in the upper body. Usually for 2–4 minutes. Can be associated with sweating, palpitations, or anxiety) Night Sweats Mood swings Sleep disturbance Memory issues Concentration problems Joint aches The Menopause comes after the peri-menopause and is when your periods have stopped by themselves completely for a period of 1 year. You may continue to experience the symptoms above. First let’s make sure you have no bleeding between periods. This is not a menopause symptom. If you have this, please do not proceed and phone the practice instead. * I do not have any bleeding between periods How are your Periods? * My periods are normal or have only been irregular for less than 3 months My periods are have been abnormal (irregular) for more than 3 months I do not have periods because I have a coil, I take other hormonal contraception or I don’t have a womb (hysterectomy) My periods stopped by themselves over 1 year ago Unlikely menopause Irregular periods for over 3 months is a hallmark of the peri-menopause. Without a change in your periods, your symptoms are very unlikely to be due to peri-menopause. Please describe the symptoms you are experiencing and we will be in touch. * In what way have your periods been abnormal (irregular)? * Longer Shorter Heavier Lighter They have stopped completely What other symptoms of the peri-menopause do you have? * Hot flushes Night Sweats Mood Swings Poor concentration or memory Memory issues Concentration problems Sleep disturbance None of these symptoms Any other symptoms you think may be related to peri-menopause? You have reached the end of the form. On submission a clinician will review your answers and be in touch with the next steps which may include blood tests, an appointment or our form explaining your treatment options. 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. Consent * I agree to the privacy policy © 2022 Kristian Turnbull CAPTCHA Submit If you are human, leave this field blank.
