Remuera & Mission Bay Doctors Menopause Questionnaire
These questionnaires guide us in supporting both your physical and emotional health.
Full Name
*
Date of Birth
*
-
Day
-
Month
Year
Date
Phone number
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Residential Status
*
Please Select
Eligible Non New Zealand
New Zealand
Non-New Zealand
If you’re not enrolled with Remuera Doctors or Mission Bay Doctors, who is your main healthcare provider?
Do you consent for us to share records with your primary healthcare provider?
Yes
No
Pre-payment is required before appointment booking
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Menopause consultation (Nurse + Doctor appointment - 60 minutes
$
490.00
NZD
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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Menopause Symptom Checklist - General Symptoms
Symptoms of perimenopause and menopause are different for everyone. Please select the option that best describes which symptoms are bothering you.
Hot flushes
Not at all
A little bit
Quite a bit
Extremely
Night sweats
Not at all
A little bit
Quite a bit
Extremely
Light-headed feelings
Not at all
A little bit
Quite a bit
Extremely
Headaches
Not at all
A little bit
Quite a bit
Extremely
Irritability
Not at all
A little bit
Quite a bit
Extremely
Low mood or loss of joy
Not at all
A little bit
Quite a bit
Extremely
Anxiety
Not at all
A little bit
Quite a bit
Extremely
Panic attackes
Not at all
A little bit
Quite a bit
Extremely
Mood swings
Not at all
A little bit
Quite a bit
Extremely
Brain fog
Not at all
A little bit
Quite a bit
Extremely
Poor Sleep
Not at all
A little bit
Quite a bit
Extremely
Fatigue
Not at all
A little bit
Quite a bit
Extremely
Backache
Not at all
A little bit
Quite a bit
Extremely
Muscle or joint pains
Not at all
A little bit
Quite a bit
Extremely
Restlless legs
Not at all
A little bit
Quite a bit
Extremely
New facial hair
Not at all
A little bit
Quite a bit
Extremely
Hair thinning
Not at all
A little bit
Quite a bit
Extremely
Dry skin
Not at all
A little bit
Quite a bit
Extremely
Crawling feelings under the skin
Not at all
A little bit
Quite a bit
Extremely
Ringing in the ears (tinnitus)
Not at all
A little bit
Quite a bit
Extremely
Dry eyes
Not at all
A little bit
Quite a bit
Extremely
Heart palpitations
Not at all
A little bit
Quite a bit
Extremely
Weight gain
Not at all
A little bit
Quite a bit
Extremely
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Menopause Symptom Checklist - Genitourinary Symptoms
Low libido
Not at all
A little bit
Quite a bit
Extremely
Dry vagina
Not at all
A little bit
Quite a bit
Extremely
Uncomfortable sex
Not at all
A little bit
Quite a bit
Extremely
Bleeding after sex
Not at all
A little bit
Quite a bit
Extremely
Vulval pain or itching
Not at all
A little bit
Quite a bit
Extremely
Irregular periods
Not at all
A little bit
Quite a bit
Extremely
Painful smear test
Not at all
A little bit
Quite a bit
Extremely
Frequent urination
Not at all
A little bit
Quite a bit
Extremely
Stress incontinence (e.g. when you cough, sneeze or laugh)
Not at all
A little bit
Quite a bit
Extremely
Urge incontinence (need to go NOW!)
Not at all
A little bit
Quite a bit
Extremely
Prolapse
Not at all
A little bit
Quite a bit
Extremely
Recurrent urinary infections
Not at all
A little bit
Quite a bit
Extremely
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PHQ-9 - Depression Symptoms
Over the last 2 weeks, how often have you been bothered by the following problems?
PHQ-9 Assessment
Rows
Not at all
Several days
More than half the days
Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired of having little energy
Poor appetite or overeating
Feeling bad about yourself - or that you are failure or have let yourself or you family down
Trouble concentrating on things, such as reading or watching television
Moving or speaking slowly - or being fidgety/restless more than usual
Thoughts that you would be better off dead or of hurting yourself
Calculation
How difficult have these problems made it for you to work, manage home life, or get along with others?
Not Difficult at all
Somewhat difficult
Very difficult
Extremely difficult
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GAD-7 - Anxiety symptoms
Over the last 2 weeks, how often have you been bothered by any of the following problems?
GAD-7 Assessment
Rows
Not at all
Several days
More than half the days
Nearly everyday
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless it's hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awaful might happen
Calculation
How difficult have these problems made it for you to work, manage home life, or get along with others?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
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