Women’s Nutritional Advisory Service - Maryon Stewart



The Really Useful Health Company162 Warren Rd, Brighton BN2 6DD(01273) 60969907460 684409 Email: maryon@ emma@MENOPAUSE QUESTIONNAIRE A. NAME ____________________________________________________________ Age ___________ Date _________________ADDRESS ____________________________________________________________________________________________________________Postcode _____________________ Tel. No ________________________ Work Tel. No ___________________________Email: ______________________________________________________________________________________________________Please complete all the questions on this form to the best of your ability. The information you provide will enable us to give you the best service we possibly can. The information you give will be respected and used only by us for your benefitSTRICT CONFIDENTIALITY WILL BE OBSERVEDB.MARITAL STATUSSingle _______ Married ________ Divorced ________ Separated ________ Widowed __________Height ______ ft ______ins Average weight _______st _______lbs Average waist measurement ____________ Hip measurement _____________C. CONTRACEPTIONAre you still using contraception? Yes/No If yes, please give details ________________________________________Have you ever taken Oral Contraceptives? Yes _________ No __________If so, did you notice any side effects when on off the Pill? Yes ________ No ________ or coming off the pill? Yes __________ No ___________Have you taken oral contraceptives in the last twelve months? Yes ________ No ________D.PERIODS (delete as applicable)How frequent were/are your periods? ______________ How long did/do your periods last for? ________________ Your periods were/are light _____ moderate ____ heavy______How long ago was your last period? __________E.PREGNANCIESPlease answer the following carefully. How many:-Pregnancies have you had? ___ Miscarriages/abortions have you had? _ Successful pregnancies have you had? ___Current ages and birth weight of your children1st child age _______ weight _____lbs ____ oz 2nd child age _______ weight ______lbs _____oz3rd child age ________weight _____lbs _____ oz 4th child age _______ weight ______lbs _____ ozDid you breastfeed if so, for how many months in total? _________ monthsF. SOCIAL CIRCUMSTANCESDo you work as a housewife? Full time _________ Part time _________ Not at all ________Do you have an occupation (as well)? Yes _______ No _________If so, what is it? _______________________________________ Do you work: Full-time ____ Part-time _____Do you have a regular sexual partner? Yes _____ No _____ Do you live together? Yes _______ No _______G. CURRENT USE OF VITAMINS / DRUGS etc.Are you currently taking: (Please state dosage and brand)Vitamins____________________________________________________________________________________________Minerals ____________________________________________________________________________________________Other natural products_________________________________________________________________________________Are you currently taking Hormone Replacement Therapy? Yes ____ No____ Pill/Patch/Implant ___________________Have you had any side effects to HRT ? (if yes please give details) _____________________________________________For how long did you take HRT? __ months ___ years Did you stop HRT because of side effects or dissatisfaction? Yes _____ No ______Which of the above have you taken for the menopause?______________________________________________________ H.ARE YOU CURRENTLY UNDER MEDICAL TREATMENT? Yes _______ No ______Details please ___________________________________________________________________________________Have you had any previous treatment for the menopause? Yes _________ No __________If yes, what was it and was it of any help? Give details ____________________________________________________________________________________________________ ____________________________________________________________________________________________________I.CURRENT SYMPTOMS Do you suffer from any of the following. Please ensure symptom is only ticked once.* How many times per monthNONEMILDMODERATESEVERE1. Hot/Cold flushes *2. Facial/Body flushing *3. Night sweats *4. Palpitations *5. Panic attacks *6. Generalised aches and pains7. Depression8. Perspiration9. Numbness/skin tingling in arms and legs10. Headaches11. Backaches12. Fatigue13. Irritability14. Anxiety15. Nervousness16. Loss of confidence17. Insomnia18. Giddiness/Dizziness19. Difficulty/frequency in passing water20. Water retention21. Bloated abdomen22. Constipation23. Itchy vagina24. Dry vagina25. Painful intercourse26. Decreased sex drive27. Loss of concentration28. Confusion/Loss of vitalityAre any of the above symptoms cyclic? (i.e come in cycles, for example on a monthly basis) __________________________________________________________________________________________________________________________ J.Have you noticed since the onset of the menopause? 1. Loss of height: Yes/No If yes, how much ________ 2. Difficulty in bending: Yes/No 3. Increased curvature of back: Yes/NoK.Have you gained weight since you started the menopause? Yes /No If yes, how much ______Do you have any other menopausal symptoms not mentioned above? ____________________________________________Did you suffer from pre-menstrual tension prior to the menopause? Yes /No If yes, for how long? __________________If yes, were your symptoms mild __________ moderate __________ severe _________L. RECENT MEDICAL HISTORY Please answer the following question carefully. Do you have any of the following complaints or have you suffered from them in the last 5 years?YesNo1. Infertility2. Epilepsy3. Eczema4. Asthma5. Hayfever6. Nettle rash/Urticaria7. Migraine8. Depression9. More than one mouth ulcer per year10. More than 2 episodes of cystitis in the last 5 years11. Herpes - cold sore face/mouth12. Herpes - genital or vaginal13. More than 2 episodes of thrush in the last 5 years14. Anaemia15. Breast disease /problems (not cancer) 1.___________________________________________2.___________________________________________3.___________________________________________ 4.___________________________________________5.___________________________________________6.___________________________________________ 7.___________________________________________8.___________________________________________9.___________________________________________10.__________________________________________11.__________________________________________12.__________________________________________13.__________________________________________14.__________________________________________15.__________________________________________Which of the above, if any, is a particular problem to you at present ____________________________________________M.MEDICAL HISTORY Have you ever had:YesNo1. Diabetes2. Thyroid disease3. Other hormonal problems4. Breast cancer5. Cancer of the cervix of the womb6. Ovarian Cysts7. Endometriosis8. Cancer other than above9. Any Gynaecological operationsGive details of the above and which of these, if any, do you have at present ________________________________________________________________________________________________________________________________________N.CURRENT HEALTH STATEDo you suffer from:Yes No1. Diarrhoea 1. ________________________________________2. Constipation 2._________________________________________3. Excessive wind 3.__________________________________________4. Itchy bottom 4.__________________________________________5. Acne 5.__________________________________________6. Greasy facial skin 6.__________________________________________7. White spots on nails 7.__________________________________________8. Split brittle nails 8._________________________________________9. Sore tongue 9.__________________________________________10. Cracking at corners of the mouth10.__________________________________________11. Poor hair growth11.__________________________________________12. Dandruff12.__________________________________________13. Dry/ Rough red pimply skin on your upper arms or thighs13.__________________________________________Which of these, if any, is a problem to you now______________________________________________________________O.oo Since the onset of the Menopause: Mildly Moderately GreatlyHas the condition of your skin deteriorated?Has the condition and texture of your hair altered?Has the condition of your nails been affected?P. DIETARY QUESTIONNAIRE1. IN A DAY How many cups/mugs do you drink of:Tea ________ Coffee _________2. How many teaspoons of sugar do you add to yourTea ________ Coffee _________3. On average how many cigarettes do you smoke per day _________4. On average how many ‘units’ of alcohol do you consume per day _________ (1 unit = 1 glass of wine = 1/2 pint of beer/lager = 1 spirit = 1 sherry/vermouth)Answer the following question carefully. Tick one5. Are you either: a VEGAN (eating only vegetable produce) _______ a VEGETARIAN (eating anything except meat, poultry or fish) ______ or an OMNIVORE (eating anything including some meat, poultry and fish) ________IN A WEEK How many servings/portions do you have of: Green vegetables __________ Salads ____________ Red meat ____________ Fruit _______________Cake/Biscuits _________ ( 1 portion = 1cake = 3 biscuits) Chocolate ________Puddings/Ice-cream/Sweet pies ____Soft drinks ________ (not low calorie) 1 can = 1 portion Chocolate based food/drinks ___ Cola based drinks ____IN A DAY How many of the following foods would you normally eat:Bread: Slices of: Wholemeal (not brown bread) __ White or brown (not wholemeal) __ Bran, bran based cereal, muesli ___Portions of dairy products ( 1 portion = 4 oz milk = 4 oz yoghurt (1 serving) = 2 oz cheeseMilk _________ Yoghurt _________ Cheese _________ Butter ________ Other animal fat __________Do you add salt to your cooking? Yes _____ No ____ Do you add salt to your food at the table? Yes ___ No __Q.CRAVINGS At any time of the month do you crave any of the following foods:Chocolate Yes ____ No _____ Sweets Yes _____ No _____ Alcohol Yes _____ No ______Savoury foods Yes _____ No _____ Other foods Yes _____ No ______ Give details __________________________R.EXERCISEHow many times a week and for how long do you do an areobic exercise. (i.e one that increases your heart rate) e.g. swimming, cycling, running ________________________________________________________________________S.BEHAVIOUR AND SOCIAL ACTIVITIES1. For how long have you had significant menopausal symptoms? Years ________ months ________Do you consider that the menopausal symptoms have adversely affected the following, if yes score as follows.-190503810Score 1=Mild 2=Moderate 3=Severe00Score 1=Mild 2=Moderate 3=Severe2. Your home life/relationships with family/friendsYes ____ No ____ 1 ____ 2 ____ 3 _____3. Your work/career (leave blank if working as a housewife full time)Yes ____ No ____ 1 ____ 2 ____ 3 _____4. Your relationship with your sexual partnerYes ____ No ____ 1 ____ 2 ____ 3 _____HAVE YOU EVER5. Contemplated suicide whilst suffering from the MenopauseYes _______ No _______ If yes, how many timesOnce ___ more than once ___ more than 6 times ____6. Been violent/aggressive towards others whilst suffering from the Menopause Yes _______ No _______ If yes, how many timesOnce ____ more than once ____ more than 6 times ___7. What is the worst problem the menopause has created for you ______________________________________________________________________________________________________________________________________T. 1. Do you drive a car?Yes _______ No ________2. Do you consider your driving ability is affected by your symptoms. Increased/decreased/the same3. How do you consider your work efficiency/productivity is affected Increased/decreased/the same by the menopause. If decreased by how many days?1-2 _____2-3 ______ 3-4 ______More ______4. Do you think that other people, family, friends and work associates are aware of a change in your behaviour when you are suffering?Yes ____ No ____ Give details____________________________________________________________________________________________________5. Since being menopausal has your frequency of sexual intercourse: Increased/decreased/the same If decreased, please score as above1 ________ 2 _______ 3 _______6. Since being menopausal has your enjoyment of sexual intercourse:Increased/decreased/the same If decreased, please score as above1 ________ 2 ________ 3 ________WHAT ARE YOUR WORST MENOPAUSE SYMPTOMS?HOW DID YOU HEAR ABOUT THE REALLY USEFUL HEALTH COMPANY? ____________________________________________________________________________________________________WHAT PROMPTED YOUR DECISION TO USE THE REALLY USEFUL HEALTH COMPANY? ____________________________________________________________________________________________________IS THERE ANYTHING ELSE YOU WOULD LIKE TO MENTION? Thank you for completing this questionnaireCopyright N.H.A.S. September 2007 ................
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