Pre-Consultation Questionnaire - CleopatraRX Pre-Consultation Questionnaire %

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Before your consult, please complete the health questionnaire so your nurse can review your history, medications, and symptoms. This ensures your time together is focused on personalized guidance and next steps.

Name(Required)

First Last

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What is your weight?(Required)

Date of birth(Required)

What is your height?(Required)

Do you have any drug or food allergies? If yes, please list them. If no, state "none".(Required)

Do you currently take Hormone replacement therapy: (estrogen, estradiol (oral/patch/vaginal), estriol, progesterone)? If yes, what was the dose & for how long?(Required)

Aside from the HRT described above, please list all of your current medications.(Required)

Are you a smoker (current, past, never)?(Required)

Do you have high cholesterol? If yes, is it controlled with treatment?(Required)

Do you have high blood pressure? If yes, is it controlled with treatment?(Required)

When was your last Gynecological visit?(Required)

0-12 months

13-24 months

24 months or more

I confirm that I have had a mammogram in the last 2 years and there was no evidence of breast cancer. (Dense breast tissue and fibrocystic disease are not related and do not apply)(Required)

Yes

No

Have you had surgical menopause?(Required)

Yes, uterus removed (hysterectomy), both ovaries still present.

Yes, both ovaries removed (ovariectomy/oophorectomy), uterus still present.

Yes, uterus and both ovaries removed.

Yes, only one ovary removed (partial ovariectomy/oophorectomy), uterus and other ovary still present.

Yes, uterus and one ovary removed, one ovary present.

No, I still have uterus and both ovaries.

Other

If you answered "Yes" to the previous question, what is the approximate time frame?(Required)

Less than 1 year ago.

Less than 5 years ago.

Between 5 and 10 years ago.

Over 10 years ago.

N/A

Please select an option below that best describes your menstrual cycle.(Required)

I have regular periods.

I have irregular periods.

My periods stopped within the past 6 months.

My periods stopped completely over 6 months ago.

Other

Which symptoms of menopause have you noticed?(Required)

Hot flashes

Difficulty sleeping

Brain fog

Daytime fatigue

Sexual dysfunction

Skin aging

None

Other

How would you rate your difficulty with problem solving (as compared to 10 years ago)?(Required)

Severe difficulty (>50% worse)

Moderate difficulty (25% worse)

Mild difficulty (<10% worse)

No difficulty

How would you rate your difficulty with finding the right words during conversations (as compared to 10 years ago)?(Required)

Severe difficulty (>50% worse)

Moderate difficulty (25% worse)

Mild difficulty (<10% worse)

No difficulty

How would you rate your difficulty with concentrating (as compared to 10 years ago)?(Required)

Severe difficulty (>50% worse)

Moderate difficulty (25% worse)

Mild difficulty (<10% worse)

No difficulty

How would you rate your difficulty with brain fog (as compared to 10 years ago)?(Required)

Severe difficulty (>50% worse)

Moderate difficulty (25% worse)

Mild difficulty (<10% worse)

No difficulty

How would you rate your difficulty with remembering things (as compared to 10 years ago)?(Required)

Severe difficulty (>50% worse)

Moderate difficulty (25% worse)

Mild difficulty (<10% worse)

No difficulty

How would you rate your difficulty with quickly processing new information (as compared to 10 years ago)?(Required)

Severe difficulty (>50% worse)

Moderate difficulty (25% worse)

Mild difficulty (<10% worse)

No difficulty

Approximately, what is your highest level of education (since this can affect brain fog)?(Required)

Less than 12 years

12 years (total years or high school grad or GED)

16 years (total years or college grad)

More than 16 years (master’s or other advanced degree or other total years of education)

How would you rate your overall quality of life now on a scale from 1-10? (10=great, 5=fair, 1=poor)(Required)

How did you hear about us?(Required)

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