Manage My Menopause

Your medical history

Please tell us about your medical history as this influences you future health and allows us to advise you on whether these medications could influence other treatments you may wish to use

Please indicate if you have any of the following chronic medical conditions

Tick all that apply

Have you been diagnosed with endometrial, ovarian or breast cancer?

Yes
No

Have you ever had a blood clot?

We would like to find out your risk of blood clots such as a deep vein thrombosis (DVT) or a pulmonary embolism (PE), so that we advise you about the risk of these conditions in the future and how safe medication such as hormone replacement therapy may be for you

Yes
No

What age were you when a DVT or PE was first diagnosed?

If unknown leave blank

What treatment did you receive?

Have you had more than one blood clot?

Yes
No

Did this occur whilst you were taking anticoagulant medication?

Yes
No

Are you currently taking anticoagulant medication?

Yes
No

Have you ever been tested for blood clotting disorders (sometimes called a thrombophilia screen)?

Yes
No

Did the test reveal a clotting problem?

Yes
No

Please tick all that apply

Factor V Leiden mutation (most common).
Prothrombin gene G20210A mutation.
Antithrombin III deficiency.
Protein C deficiency.
Protein S deficiency.
Hyperhomocysteinaemia.
Dysfibrinogenaemia.
Disorders of plasminogen and plasminogen activation.
I do not know

Do you have any of the following risk factors for venous thromboembolism?

Please tick all that apply

Immobility (do you have a condition that limits your mobility or requires frequent bed rest)
Do you go on frequent (more than once/month) long haul journeys (>4 hours)?
Family history of a first degree relative ( your parent, sibling or child) who had a blood clot under the age of 50 years

Was a reason for the blood clot found?

Yes
No
Don't know

Have you been diagnosed with Cardiovascular (Heart) Disease?

Yes
No
Don't know

What conditions have you been diagnosed with?

Please tick all that apply

Ischaemic Heart Disease
Myocardial Infarction
Angina
TIA (mini stroke)
Stroke
Peripheral vascular disease

Do you have high blood pressure (a condition call hypertension)?

Yes
No
I’d rather not say

Do you take medication to control your blood pressure?

Yes
No
I'd rather not say

Do you know your most recent blood pressure reading? When blood pressure is taken you get two numbers systolic pressure/diastolic pressure, often said as one number over another number e.g. 120 over 80.

Systolic Pressure

Diastolic Pressure

Have you had a test of your cholesterol?

Yes
No
I Dont know

If you know them, please enter your Cholesterol readings here

Total cholesterol

Blood cholesterol is measured in units called millimoles per litre of blood, often shortened to mmol/L

HDL cholesterol

High-density lipoprotein (HDL) measured in units called millimoles per litre of blood, often shortened to mmol/L

Cholesterol ratio

Your ratio of total cholesterol to HDL

Do you have a family history of cardiovascular disease?

Have any of your first degree relatives (your parents, siblings or children) been diagnosed with cardiovascular disease at less than 60 years of age?

Yes
No
I Don't know

Do you know your QRISK®2 Score?

Yes
No
I do not know

The QRISK®2 score is your risk of having a heart attack or stroke over the next ten years. To calculate your QRISK®2 you need to visit an external website. The link is below. Please complete the QRISK®2 questions and enter your score

Please provide your 10-year QRISK®2 score, if you know it

If you'd rather not say, please leave this field blank, please enter a number only

Do you have any risk factors for osteoporosis?

Please tick all that apply.

A previous osteoporotic bone fracture (a previous fracture that occured spontaneously, or a fracture that occurred from an injury that, in a healthy individual, would not have resulted in a fracture i.e. a minor injury)
One of your parents had a hip fracture
You currently take oral steroid tablets for a health condition or have done so for at least 3 months in the past
Recently lost a lot of weight
Difficulty eating or a very low calorie diet
Low calcium intake
Vitamin D deficiency
Malabsorption disorder

Do you know your FRAX® Risk score?

Yes
No
I dont know

FRAX® Risk score

Please provide your ten year probability of major osteoporotic fracture, if you know it. If you'd rather not say, please leave this field blank, please enter a number only

Do you know your QFracture® Risk score?

Yes
No
I Dont know

Please provide your QFracture® Risk score of osteoporotic (hip, wrist, shoulder or spine) fracture, if you know it.

If you'd rather not say, please leave this field blank, please enter a number only

Have you had any of the following operations?

Hysterectomy
Removal of both of your ovaries
Removal of your Fallopian tubes
Prolapse surgery
Surgery for continence problems

Have you ever used HRT?

Yes
No

What type of HRT have you used?

How long did you use/have you used HRT for?

How would you describe your views on HRT?

Positive
Negative
Uncertain/undecided

Name

This field is for validation purposes and should be left unchanged.

Step 1 of 6 - Contact Information

Step 2 - Details about your menopause

Details about your lifestyle

Family History

Your medical history

Menopause Advice

Step 1 of 6 - Contact Information

Step 2 - Details about your menopause

Details about your lifestyle

Family History

Your medical history