Stonyhill Medical Practice

South Shore Primary Care Centre, 575 Lytham Road, Blackpool, FY4 1TJ

Telephone: 01253 201365

blackpool.stonyhilladmin@nhs.net

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Menopause- Symptom submission

Menopause- Symptom submission

Menopause Symptom Checklist

You have been asked to complete this form so the practice can gather as much information about your symptoms before your appointment.

Name(Required)

First Last

Contact Telephone number(Required)

Date of birth(Required)

MM slash DD slash YYYY

Do you suffer with any of the following symptoms?

Untitled

Anxiety

Low mood

Depression

Mood swings

Crying spells

Brain fog

Loss of confidence

Poor concentration

Poor memory

Loss of joy

Reduced self esteem

Irritability

Heart palpitations

Difficulty sleeping

Tired/ Lack of energy

Headaches

Painful/Aching joints

Hot flushes

Night sweats

Changes to period

Vaginal Symptoms

Urinary symptoms

Loss of libido

Feeling faint/dizzy

Dry eyes/ears

Oral health changes

Thinning hair

Dry/itchy skin

Tinnitus

Restless legs

Change to body odour

Increased allergies

Digestive issues

Please describe the symptoms you have been having(Required)

Do you smoke?(Required)

Yes

No

Do you need contraception?(Required)

Yes

No

Unsure

Have you tried anything for your symptoms?(Required)

Yes

No

If yes what have your tried?

When was your last period?

MM slash DD slash YYYY

Do you have any family history or blood clots or stroke?(Required)

Yes

No

Unknown

How much alcohol do you drink per week?(Required)

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I consent to my data being stored according to the Privacy Policy

Follow this link to access Privacy Policy

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Menopause -Symptom Submission
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Opening Times

Monday
08:00am to 06:30pm
Tuesday
08:00am to 06:30pm
Wednesday
08:00am to 06:30pm
Thursday
08:00am to 06:30pm
Friday
08:00am to 06:30pm
Saturday
CLOSED
Sunday
CLOSED

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Update your details

"*" indicates required fields

Name*

First Last

Date of Birth*

Address*

Phone*

Email*

Smoking Status*

How many per day?*

Follow this link to access Privacy Policy

I consent to my data being stored according to the Privacy Policy

Follow this link to access Privacy Policy

Name

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

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Register with the Practice

"*" indicates required fields

Patient details

Title*

Date of Birth*

DD slash MM slash YYYY

Gender*

NHS Number

First Names*

Birth Town*

Surname*

Birth Country*

Current Address and Postcode*

Telephone*

Mobile*

Email Address*

Please help us trace your previous medical records by providing the following information

Have you previously been registered with an NHS GP in UK?*

Yes

No

Name of Previous GP*

Address of Previous GP*

Your Previous Address

This is usually the address when you were last registered with a GP

Your first UK address*

Date you first came to UK

DD slash MM slash YYYY

Are you returning from the Armed Forces?*

Yes

No

Please indicate if you have ever served in the UK Armed Forces and/or been registered with a Ministry of Defence GP in the UK or overseas*

Regular

Reservist

Family Member

Address and Postcode before enlisting*

Service or Personnel Number*

Enlistment date*

If you are registering a child under 5

Child Health Surveillance

I wish the child above to be registered with the named doctor for Child Health Surveillance

If you need a doctor to dispense medicines and appliances

Nearest Chemist

I live more than 1 mile in a straight line from the nearest chemist

Chemist Difficulty

I would have serious difficulty in getting them from a chemist

Signatures

Signatures*

Patient's signature

Signature on behalf of patient

Consent

I agree for the Practice to contact me using the details provided above.

Electronic Signature (Type your full name here)*

By completing the section above, I hereby sign this form electronically

NHS Organ Donor Registration

Would you like to join the NHS Organ Donor Register?*

Yes

No

Already on it

I want to register my details on the NHS Organ Donor Register as someone whose organs/tissue may be used for transplantation after my death.*

Any of my organs and tissue

Kidneys

Heart

Liver

Corneas

Lungs

Pancreas

NHS Blood Donor Registration

Would you like to join the NHS Blood Donor Register?*

Yes

No

Already on it

Tick here if you have given blood in the last 3 years

I have given blood in the last 3 years

My preferred address for donation is:

Follow this link to access Privacy Policy

I consent to my data being stored according to the Privacy Policy

Follow this link to access Privacy Policy

Comments

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

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