Menopause Retreat Form Name :*Date of Retreat :* DD slash MM slash YYYY Date of last menstrual period :* DD slash MM slash YYYY Cycle Pattern :* Regular Irregular Cycle Flow :* Light Normal Heavy Any gynaceological history ie fibroids, endometriosis, ovarian cysts etc :*Previous history of PMT/ fluid retention :Has the doctor confirmed you are indeed experiencing the menopause?* Yes No Any blood test results (if known) :Are you taking HRT?* Yes No If yes, how long for and which one?History of smoking :*Menopause history of mother and grandmother if known :*History of medical procedures such as hysterectomy, contraceptive pills :*Are you experiencing any of the following symptoms? Please tick all of the symptoms that apply.* Muscle and joint pain/aches Emotional changes Mood swings Irritability Sadness Anxiety Aggressiveness Vaginal dryness Increased need for sleep Difficulty with concentration Difficulty making decisions Loss of enjoyment of things that were once pleasurable Lack of motivation in other areas of life or in general Fatigue Weight loss Weight gain Change in appetite Migraines/Headaches Are you experiencing hot flushes?* Yes No If yes, are they : At night During the day All the time Are the hot flushes causing you concern? Yes No When did your symptoms start?*What are your sleep patterns like?*Any other information you feel we may need to know?* Δ
