What is your current age?
Under 4040 - 4445 - 4950 - 5455 – 60Over 60

Are you
EmployedUnemployedSelf-employed

Are you
MarriedDivorcedSingleIn a relationship

Do you have children?
YesNo

Do you think you're menopausal?
YesNoDon't know

Have you experienced any of the common menopausal symptoms?
YesNo

Have you experienced any of the following symptoms?

Hot Flushes
YesNo

Night Sweats
YesNo

Brain Fog
YesNo

Palpitations
YesNo

Anxiety
YesNo

Irritability
YesNo

Low Mood/Depression
YesNo

Weight Gain
YesNo

Insomnia
YesNo

Fatigue
YesNo

Aching bones
YesNo

Thinning hair
YesNo

Dry skin
YesNo

Vaginal Dryness
YesNo

Painful sex
YesNo

Stiff Joints
YesNo

Loss of Libido
YesNo

IBS
YesNo

What age did you notice your first symptoms of menopause?
Under 4040 - 4445 - 4950 - 5455 – 60Over 60

Did you feel well informed about the menopause before experiencing symptoms?
YesNo

Did you understand the changes in your hormones before experiencing your menopause symptoms?
YesNo

Have menopause symptoms affected your home life?
YesNo

Has menopause affected your relationship with your children?
YesNoNot Applicable

Has the menopause affected your relationship with your partner?
YesNoNot Applicable

Has the menopause affected your relationship with your friends?
YesNoNot Applicable

Have you discussed symptoms/experience with your family?
YesNo

Have you discussed symptoms/experience with your friends?
YesNo

Have any of the below been your coping mechanisms?
YesNo

Alcohol Abuse
YesNo

Smoking/ E-cigarettes
YesNo

Excessive Exercise
YesNo

Seeking out medications
YesNo

Sleeping Pills
YesNo

Sleeping all the time
YesNo

Avoiding social situations
YesNo

Avoiding communication with friends and family
YesNo

Have your friends or family ever commented on your change of mood/behaviour during your menopause?
YesNo

Have your menopause symptoms affected you at work?
YesNo

Have you discussed symptoms with your employer/line manager?
YesNo

Do you feel comfortable talking to your employer/line manager about your symptoms?
YesNo

In the past year, how much time have you taken off work due to menopausal symptoms or seeing health care providers to deal with symptoms? (Either using sickness or annual leave)
None1 - 5 days6 - 12 daysMORE than 12 days

Does your current place of work offer menopausal aid?
YesNoNot Applicable

Would you like your employer to provide menopause help and information through your workplace?
YesNoNot Sure

Has the menopause affected your sex life?
YesNo

Have you spoken about how the menopause has affected your sex life with your partner?
YesNoNot Applicable

Are you currently taking HRT?
YesNo

Did you have reservations worries on taking HRT?
YesNo

Have your Health Care Services been receptive to your symptoms and advised you well on menopause?
YesNo

Did your doctor prescribe you other medication before HRT?
YesNoNot Applicable

How easy has it been to find and receive support/advice about menopause that is personal to you at your GP or other practices?
YesNo