Menopause Checklist

If you have been asked by the surgery to do so, please submit this form.

This will be really useful to asses you and also to evaluate your response to any treatment.

Menopause Checklist


Blood Pressure

For a list of validated home blood pressure monitors, visit or discuss with your pharmacy.

Please use date format: DD/MM/YYYY


eg. 1.75
eg. 60.6

For more information, please visit NHS: Healthy Weight.


Please indicate the extent to which you are bothered at the moment by any of these symptoms:

Heart beating quickly or strongly: *
Feeling tense or nervous: *
Difficulty in sleeping: *
Excitable: *
Attacks of anxiety, panic: *
Difficulty in concentrating: *
Feeling tired or lacking in energy: *
Loss of interest in most things: *
Feeling unhappy or depressed: *
Crying spells: *
Irritability: *
Feeling dizzy or faint: *
Pressure or tightness in head: *
Parts of body feeling numb: *
Headaches: *
Muscle and joint pains: *
Loss of feeling in hands or feet: *
Breathing difficulties: *
Hot flushes: *
Sweating at night: *
Loss of interest in sex: *