Home
About
About Us
Values
Team
Specialist Centre
Services
Patient Forms and Links
Our Doctors
Medical Education
Medical Education
Courses for Specialists
Courses for General Practitioners
Contact Us
After Surgery Care
Course Intranet
Home
About
About Us
Values
Team
Specialist Centre
Services
Patient Forms and Links
Our Doctors
Medical Education
Medical Education
Courses for Specialists
Courses for General Practitioners
Contact Us
After Surgery Care
Course Intranet
Menopause Specialist - Hormonal Questionnaire
Dr Fatima Khan
Name
*
First Name
Last Name
Mobile Phone
*
Email
*
Regular GP
*
Occupation
*
Marital Status
*
Number of Children
*
Age of Children
*
Height (cms)
*
Weight (Kgs)
*
Blood Pressure
*
Are you currently using or have used Hormone Therapy (HRT)
*
Yes
No
If Yes, please specify:
Are you currently using contraception
*
Yes
No
If yes, please Specify
Describe your menstrual cycle:
*
Please include duration, frequency and bleeding pattern. If you no longer have a cycle, please record the approximate date it ceased.
Tick if you have the following symptoms
Hot flushes
Night sweats
Sleep disturbance
Headaches
Joint aches
Mood changes
Facial hair
Hair loss
Vaginal dryness
Low libido/sexual desire
Uncomfortable sexual intercourse
List any medical problems that other doctors have diagnosed. Please include dates if possible.
Have you had a blood cloth in the past
*
Yes
No
Have you ever had breast cancer?
*
Yes
No
List any surgeries/hospitalisations
*
Please add dates
List any drug allergies and reactions you have had
*
List your current prescribed medications:
*
List any over the counter medications, vitamins, herbs:
*
Are you a current smoker
*
Yes
No
If so, how many per day?
Do you consume alcohol?
*
Yes
No
If so, how many standard drinks and how often?
How often do you exercise?
*
What type of exercise do you do?
*
Describe your eating habits:
*
How would you rate your diet?
*
How would you rate your stress levels?
*
When was your most recent mammogram?
*
When was your most recent cervical screen (Pap smear)?
*
Have you had a bone density scan (DEXA)?
*
If yes, what was the result?
List any significant family medical history:
*
Would you like correspondence from your consultation with Dr Khan to be sent to your GP?
*
Yes
No
How did you hear about Dr Fatima Khan?
*
Today's date:
*
Thank you!
