Assessment - MENOWAVE

Take the Assessment

Take our Free Menopause Assessment and get connected to our Care Providers for your personalized menopause analysis. Please answer all the questions below:

To ensure that you receive the highest level of support during your menopause journey, we are pleased to inform you that a dedicated Menowave care provider will be reaching out to you. The Menowave care model is specifically designed to enhance and complement the support you receive within the Menopause Support Group. By combining the expertise and resources of Menowave with the group’s framework, we aim to offer you a comprehensive and personalized menopause support experience. Our collaborative approach is centered around your well-being, and we are committed to assisting you throughout this transformative phase of life.

First Name: (required) Last Name: (required) Address: (required) City: (required) State: (required) Zip code: (required) Phone: (required) Email: (required) Birthday: Why are you here today? Main concerns or questions about this stage of life? Have you assumed menopause would be the end of your sexual life?

Yes No

Has menopause brought troublesome changes in your sexual functioning (arousal, sensations, lubrication, intercourse, orgasm…)?

Yes No

Are you feeling pressured because your partner wants intimacy and you don’t and are you afraid of losing your partner?

Yes No

Medical history- Click all that apply

Gynecologic History

Premenopause (before menopause; having regular periods) Perimenopause/Menopause transition (changes in periods, but have not gone 12 months in a row without a period) Postmenopause (after menopause)

Was your menopause:

Spontaneous ("natural") Surgical (removal of both ovaries) Due to chemotherapy or radiation therapy I have not gone through menopause
Age of first menstrual period: Are your periods (or were your periods) usully regular?

Yes No

Do you have a uterus?

Yes No

Do you have both ovaries?

Yes No

Do you have a cervix?

Yes No

If not still having periods, what was your age when you had your last period? If still having periods, how often do they occur? How many days does your period last? Are your periods painful?

Yes No

Do you have spotting or bleeding between periods?

Yes No

Is there a recent change in how often you have periods?

Yes No

Is there a recent change in how many days you bleed?

Yes No

Has your period recently become very heavy?

Yes No

Do you think you have a problem with your period?

Yes No

Do you have any problems with PMS (PMS is having mood swings, bloating, headaches just prior to your period)

Yes No

Do you examine your breasts?

Yes No

Do you douche?

Yes No

When is the date (if known) of your last Pap smear? Any abnormal Pap tests?

Yes No

When is the date (if known) of your last Mammogram? Have you had any breast biopsies?

Yes No

When is the date (if known) of your last Thyroid test? Any abnormal thyroid tests?

Yes No

When is the date (if known) of your last Cholesterol test? When is the date (if known) of your last blood sugar test? When is the date (if known) of your last fecal occult blood test? When is the date (if known) of your last colonoscopy? When is the date (if known) of your last sigmoidoscopy? When is the date (if known) of your last bone density test?

Medication History

Are you currently using hormome therapy for menopause?

Yes No

Have you used any alternative therapies for your menopause?

Yes No

If yes, Check all that apply
Acupuncture Homeopathy Hypnosis Yoga Talk Therapy Supplementation
Personal Habits
Do you consider your health to be: Excellent Good Poor

Skin

Have you noticed any significant changes in your skin? No YesWhat specific concerns do you have about your skin?

Exercise

How often do you exercise? Almost daily At least 3x/week Occasionally Rarely NeverIf you exercise, what do you do? If you exercise, how long and how often?

Diet

How many meals do you consume each day? Do you try to eat a sepcial diet? Almost daily At least 3x/week Occasionally Rarely NeverIf you consume milk each day, how much? If you consume cheese each day, how much? If you consume yogurt each day, how much? Do you consume any other dairy? If so what? Are you lactose intolerant (diarrhea or gastrointestinal/GI upset after dairy products)?

Yes No

How many of servings of fruits do you consume each day? How many servings of vegetables do you consume each day? How many servings of soy foods do you consume each week? How many servings of fish do you consume each week?

Tobacco Use

Do you currently smoke cigarettes?

Yes No

Have you ever smoked?

Yes No

Do you use any other type of tabacco?

Yes No

Caffeine Use

Do you consume drinks with caffeine (coffee, tea, soda drinks)?

Yes No

Alcohol and Drug Use

Do you drink alcohol?

Yes No

Do you ever have a drink in the morning to get you going?

Yes No

Have you ever tried to cut down on your drinking?

Yes No

Have you ever felt guilty about the amount you drink?

Yes No

Have you ever been an alcoholic?

Yes No

Do you ever use illegal drugs?

Yes No

Abuse

Within the last year, have you been hit, slapped, kicked, or physically hurt by someone?

Yes No

Within the last year, has anyone ever forced you to have sexual activities?

Yes No

Do you feel you are verbally or emotionally abused by someone?

Yes No

Have you had counseling for these issues?

Yes No

Stress Management

What are the current major stressors or life changes in your life? Any major changes in the family health during the past year?

Yes No

How do you handle stress?

Very Well Moderately Well Poorly

What do you do to relax?

About Menopause and Hormone Therapy

How do you view menopause? Positively. For example, menopause means no more periods and no more worry about contraception Negatively. For example, menopause means a loss of fertility and loss of youth Other
If Other, please specify:
What concerns you about menopause?
What concerns you most about hormone therapy for menopause?
How would you rate your knowledge about menopause? Very Good Fair Moderate Little

How do you get your information about menopause? Mark all that apply.
Books Internet Magazines Friends TV Healthcare Providers

Is there anything else you would like us to know?
Would you like to subscribe to our newsletter?
Yes No

Would you like more information on our sisterhood retreats?
Yes No

Thank you! Please note that the information you have provided will be held in the strictest confidence within our affiliate network.