Menopause Baseline Assessment QuestionnaireSection IFull Name Full NameAge AgeGender GenderMaleFemaleMarital Status Marital StatusPhone number Phone numberEmail address Email addressAt what age did you start menstruating? At what age did you start menstruating?Have your menstrual cycles become irregular? Have your menstrual cycles become irregular?If yes, when did this start?When was your last menstrual period? When was your last menstrual period?Are you experiencing any of the following symptoms? Are you experiencing any of the following symptoms?Check all that applyHot flashesNight sweatsMood changes (e.g., irritability, depression, anxiety)Vaginal drynessReduced libidoSleep disturbancesMemory or concentration issuesWeight gainOther:Have you been diagnosed with any menopause-related health issues? Have you been diagnosed with any menopause-related health issues?e.g., osteoporosis, cardiovascular conditionsHave you had a hysterectomy or any other reproductive surgeries? Have you had a hysterectomy or any other reproductive surgeries?If yes, please provide detailsDo you have a family history of menopause-related health conditions? Do you have a family history of menopause-related health conditions?Do you smoke or consume alcohol? Do you smoke or consume alcohol? If yes, how frequently?Are you physically active? Are you physically active?If yes, what type of activities and how often?Do you practice stress management techniques? Do you practice stress management techniques?If yes, please specify.Do you consume foods rich in calcium and vitamin D? Do you consume foods rich in calcium and vitamin D?If yes, please specify.How often do you consume processed or fast foods? How often do you consume processed or fast foods?Do you take any supplements? Do you take any supplements?If yes, list them.Is there anything else you would like us to know about your health or concerns? Is there anything else you would like us to know about your health or concerns?
Full Name
Age
Gender
Marital Status
Phone number
Email address
At what age did you start menstruating?
Have your menstrual cycles become irregular?
If yes, when did this start?
When was your last menstrual period?
Are you experiencing any of the following symptoms?
Check all that apply
Have you been diagnosed with any menopause-related health issues?
e.g., osteoporosis, cardiovascular conditions
Have you had a hysterectomy or any other reproductive surgeries?
If yes, please provide details
Do you have a family history of menopause-related health conditions?
Do you smoke or consume alcohol?
If yes, how frequently?
Are you physically active?
If yes, what type of activities and how often?
Do you practice stress management techniques?
If yes, please specify.
Do you consume foods rich in calcium and vitamin D?
How often do you consume processed or fast foods?
Do you take any supplements?
If yes, list them.
Is there anything else you would like us to know about your health or concerns?
