Sloan Medical Centre

0114 2581554
sloan.reception@nhs.net

Blackstock Road Surgery

0114 2581554
sloan.reception@nhs.net

Sloan Medical Centre | Medical Centre Sheffield | GP Sheffield | Care Sheffield

Menopause Symptom Questionnaire

Menopause Symptom Questionnaire

Patient's Details

Full Name *

Date of Birth *

Contact Number *

Email Address *

Which Doctor or Nurse asked you to complete this questionnaire?

Symptoms

Please indicate the extent to which you are bothered at the moment by any of these symptoms:
(Not at all = 0) (A little = 1) (Quite a bit = 2) (Extremely = 3)

Heart beating quickly or strongly *

0

1

2

3

Any comments

Feeling tense or nervous *

0

1

2

3

Any comments

Difficulty in sleeping *

0

1

2

3

Any comments

Memory problems *

0

1

2

3

Any comments

Attacks of anxiety / panic *

0

1

2

3

Any comments

Difficulty in concentrating *

0

1

2

3

Any comments

Feeling tired or lacking in energy *

0

1

2

3

Any comments

Loss of interest in most things *

0

1

2

3

Any comments

Feeling unhappy or depressed *

0

1

2

3

Any comments

Crying spells *

0

1

2

3

Any comments

Irritability *

0

1

2

3

Any comments

Feeling dizzy or faint *

0

1

2

3

Any comments

Pressure or tightness in head *

0

1

2

3

Any comments

Tinnitus (ringing or buzzing in the ear) *

0

1

2

3

Any comments

Headaches *

0

1

2

3

Any comments

Muscle and joint pains *

0

1

2

3

Any comments

Pins and needles in any part of the body *

0

1

2

3

Any comments

Breathing difficulties *

0

1

2

3

Any comments

Hot flushes *

0

1

2

3

Any comments

Sweating at night *

0

1

2

3

Any comments

Loss of interest in sex *

0

1

2

3

Any comments

Urinary symptoms *

0

1

2

3

Any comments

Symptoms due to vaginal dryness *

0

1

2

3

Any comments

I confirm that I understand ALL of the following statements *

I should call 999 if I am urgently worried about this matter

I can call 111 for more advice at any time, or if I am unsure

I can also call the medical centre on 0114 2581554

I am the patient or I have the patient's permission to submit this information

I will make a plan to consult with my practitioner to discuss these symptoms