What best describes your menstrual status?

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When was your last menstrual period?

Are you currently experiencing menopausal or perimenopausal symptoms?

Are you experiencing any of these symptoms?

How long have you been experiencing these symptoms?

How much do these symptoms affect your daily life?

Have you ever been diagnosed with, or do you have a history of, any of the following conditions?

Are you currently using hormone replacement therapy?

Are you taking any regular medication or supplements?

This includes over-the-counter medicine

Do you smoke?

Have you experienced any unexplained vaginal bleeding?

Do you agree to the following?

I have been informed about the potential side effects and interactions of the prescribed medication for Menopause.

  • I declare that I have answered all questions truthfully and to the best of my knowledge.
  • I will read the Patient Information Leaflet before taking any prescribed medication.
  • I will contact The Care Pharmacy and inform my GP if I experience any side effects, start new medication, or if my medical conditions change during treatment.
  • I understand that prescribers take my answers in good faith and base prescribing decisions accordingly, and that incorrect information can be hazardous to my health.
  • I understand that this questionnaire forms part of a request to the prescriber, and that the final decision to prescribe rests with the prescriber.
  • I consent to this consultation being used to assess my suitability for treatment.
  • I understand that my medication may require cold storage and careful handling.
  • I agree to the stated delivery terms and understand that medicines will be dispatched in line with storage and safety requirements.
  • I agree to be contacted for a follow-up video call if required.
  • I understand that I will only be charged if my consultation is approved and a prescription is issued.
  • I understand that the clinician may access my NHS Summary Care Record to support safe prescribing, including information about my medications, allergies, and adverse reactions.

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