SOLASTA PERIMENOPAUSAL / MENOPAUSE CLINIC PERIMENOPAUSAL / MENOPAUSE CLINIC Updates Patient DetailsFirst NameLast NameDate of BirthEmailPhone/MobileAddressAddress Line 1Address Line 2CityPostcodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)RomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweGP DetailsGP NameGP PracticeGP Contact NumberLifestyle FactorsDo you smoke?Alcohol intake (units per week)Exercise (type/frequency per week)Average sleep per nightDietary notes or restrictionsMenopause Symptom AssessmentPlease tick the box that best describes your symptoms.Checkbox GridNot at allA littleQuite a bitA lot / Very muchHeartbeat quickening / palpitationsTrouble breathingFeeling faint / dizzyPressure or tightness in bodyPins and needlesTinnitus / ear ringingJoint or muscle pains HeadachesHot flushesNight sweatsRestless legsDifficulty sleepingFatigue / low energyWeight gain Change in periodsLoss of interest / low motivationDifficulty concentratingWord-finding difficultyReduced ability to multitaskMemory problemsFeeling nervousEmotional changesAnxiety / panic attacksLow mood / depressionCrying spellsIrritabilityReduced / loss of sex driveVaginal drynessDry eyesUrinary symptoms (frequency/urgency/infections)Personal Medical HistoryConditionYesNoBlood clots (DVT/PE)Cardiac disease or strokeHeart attack or anginaHigh blood pressureMigraineActive liver diseaseEndometriosisDiabetesAllergiesMenstrual CycleDate of last periodAre your periods regular or irregular?Typical flow (Light / Moderate / Heavy)Are periods painful?Have your periods changed recently?Additional notesAre you using any contraception? Yes NoWhat contraception are you using?Impact on Daily LifeCheckbox GridNot at allA littleQuite a bit A lot / SeverelyAbility to workRelationship with spouse/partnerSocial lifeMedicationAre you currently on any medication? Yes NoList the medication you are currently taking.Declaration I confirm that the information provided in this questionnaire is accurate and complete to the best of my knowledge.Signature Sign Here 18/06/2026Submit
