Menopause Questionnaire

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Personal Details

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Questionnaire

Please complete this form before speaking to our specialist Menopause Nurse.

Do you use contraception?: *

Any history of migraines?: *

Any family or personal history of blood clotting disorders?: *

Any history of breast cancer?: *

Are you aged 50 or over?: *

Have you attended breast screening?: *

Are you suffering from any of the following?:

Please note this list is not exhaustive if there is anything else you wish to discuss you will have the opportunity at your initial consultation.

Prior to your call please take a look at Balance Menopause.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Menopause Questionnaire

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