Menopause questionnaire - Birmingham Menopause Clinic

Menopause Questionnaire

"*" indicates required fields

Do you still experience periods?

Yes

No

Age

Name*

First Last

Email*

1.Heart beating quickly or strongly*

Not at all	A little	Quite a bit	Extremely

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Comment

2. Feeling tense or nervous*

Not at all	A little	Quite a bit	Extremely

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Comment

3. Difficulty in sleeping*

Not at all	A little	Quite a bit	Extremely

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Comment

4. Excitable*

Not at all	A little	Quite a bit	Extremely

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Comment

5. Attacks of anxiety, panic*

Not at all	A little	Quite a bit	Extremely

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Comment

6. Difficulty in concentrating*

Not at all	A little	Quite a bit	Extremely

Let us know more about this symptom

Comment

7. Feeling tired or lacking in energy*

Not at all	A little	Quite a bit	Extremely

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Comment

8. Loss of interest in most things*

Not at all	A little	Quite a bit	Extremely

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Comment

9. Feeling unhappy or depressed*

Not at all	A little	Quite a bit	Extremely

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Comment

10. Crying spells*

Not at all	A little	Quite a bit	Extremely

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Comment

11. Irritability*

Not at all	A little	Quite a bit	Extremely

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Comment

12. Memory problems*

Not at all	A little	Quite a bit	Extremely

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Comment

13. Feeling dizzy or faint*

Not at all	A little	Quite a bit	Extremely

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Comment

14. Pressure or tightness in head*

Not at all	A little	Quite a bit	Extremely

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Comment

15. Parts of body feel numb*

Not at all	A little	Quite a bit	Extremely

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Comment

16. Headaches*

Not at all	A little	Quite a bit	Extremely

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Comment

17. Muscle and joint pains*

Not at all	A little	Quite a bit	Extremely

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Comment

18. Loss of feeling/pins and needles in hands or feet*

Not at all	A little	Quite a bit	Extremely

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Comment

19. Breathing difficulties*

Not at all	A little	Quite a bit	Extremely

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Comment

20. Hot flushes*

Not at all	A little	Quite a bit	Extremely

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Comment

21. Sweating at night*

Not at all	A little	Quite a bit	Extremely

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Comment

22. Loss of interest in sex*

Not at all	A little	Quite a bit	Extremely

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Comment

23. Urinary symptoms*

Not at all	A little	Quite a bit	Extremely

Let us know more about this symptom

Comment

24. Vaginal dryness*

Not at all	A little	Quite a bit	Extremely

Let us know more about this symptom

Comment

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