Section 1 — About You
&
Your Menopause Journey
First name
Last name
Date of birth
Month
Day
Year
Email
Phone number
Height (cm)
Current weight (kg)
Which best describes you currently?
Periods are still regular
Periods are changing but still occurring
Periods have become irregular
I believe I am in perimenopause
No period for less than 12 months
No period for 12 months or longer
Surgical menopause
Unsure
What is your main reason for having this assessment? Select all that apply.
Understand whether my body is changing through midlife
Weight gain
Increased abdominal fat
Difficulty losing body fat
Loss of muscle / strength
Fatigue / low energy
Poor sleep
Hot flushes / night sweats
Mood changes / anxiety / irritability
Brain fog / concentration problems
Increased appetite / cravings
High cholesterol / triglycerides
Prediabetes / insulin resistance
High blood pressure
Bone health / osteoporosis prevention
Gut symptoms
Healthy ageing
Improve diet quality
Supplement review
Other
Are you currently using any of the following?
Menopausal hormone therapy / MHT
Hormonal contraceptive pill
Hormonal IUD / Mirena
Other hormonal contraception
No hormonal medication
Unsure
Please provide the name/dose if known.
Have you had any of the following?
Hysterectomy
Endometrial ablation
One ovary removed
Both ovaries removed
Cancer treatment affecting ovarian function
None of the above
Next
Perimenopause & Menopause Pre-Assessment Form