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
$
490.00
NZD
Quantity
1
2
3
4
5
6
7
8
9
10
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Month
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month
Expiration Year
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
Expiration Year
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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.
Menopause Symptom Checklist - General Symptoms
*
Rows
Not at all
A little bit
Quite a bit
Extremely
Hot Flushes
Night sweats
Light-headed feelings
Headaches
Irritability
Low mood or loss of joy
Anxiety
Panic attacks
Mood swings
Brain fog
Poor sleep
Fatigue
Backache
Muscle or joint pains
Restless legs
New facial hair
Hair thinning
Dry skin
Crawling feelings under the skin
Ringing in the ears (tinnitus)
Dry eyes
Heart palpitations
Weight gain
General Symptom Score
/69
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Menopause Symptom Checklist - Genitourinary Symptoms
Menopause Symptom Checklist - Genitourinary Symptoms
Rows
Not at all
A little bit
Quite a bit
Extremely
Low libido
Dry vagina
Uncomfortable sex
Bleeding after sex
Vulval pain or itching
Irregular periods
Painful smear test
Frequent urination
Stress incontinence (e.g. when you cough, sneeze or laugh)
Urge incontinence (need to go NOW)
Prolapse
Recurrent urinary infections
Genitourary Symptoms Score
/36
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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
/27
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
/27
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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