Consultation form

SECTION 1: PERSONAL INFORMATION

Name*

Date of birth*

Age*

Email Address*

Country of residence*

Occupation*

Marital status*

single

married

divorced

widowed

other

Emergency contact name*

Emergency contact number*

SECTION 2 : APPOINTMENT DETAILS

What is the main reason for your consultation today?*

Menopause Symptoms

Perimenopause symptoms

Hormone therapy assessment

Low libido/vagina dryness/Sexual health concerns

Weight management

Sleep problems

Mood changes

Hot flashes /night sweats

Bone health concerns/osteoporosis

Palpitations/ Cardiovascular health concerns

Difficulty concentration/forgetful/brain fog/mental health problems

Other

Please describe your concerns in your own words*

SECTION 3: MENSTRUAL & REPRODUCTIVE HISTORY

At what age did your periods begin?*

Date of your last menstrual period?*

Are your periods currently :*

Regular

Irregular

Stopped completely

Not sure

Explain in your own words*

If your periods have stopped , at what age did they stop?*

Have you had:*

Natrual menopase

Surgical menopause

Hysterectomy

Removal of ovaries

Endometrial ablation

None

Number of pregnancies*

Number of live births*

Any history of infertility?*

Yes

No

Any history of miscarriages?*

Yes

No

If yes, how many?*

SECTION 4: MENOPAUSE STAGE ASSESSMENT

Which best describes you?*

Still having regular periods

Periods becoming irregular

Missed periods for several months and I am not pregnant

No periods for 12 months or more

Surgical menopause

I have a health challenge that affects my periods

I don't know my period pattern

SECTION 5: MENOPAUSE SYMPTOMS. Please tick all symptoms which you are currently experiencing:*

hot flashes

night sweats

heat intolerance

difficulty falling asleep

frequent waking up when trying to sleep

poor sleep quality

I feel anxious

I feel irritable

low mood

mood swings

loss of confidence

low self esteem

brain fog

poor concentration

memory concerns

fatigue

joint pains

muscle aches

headaches

weight gain

hair thinning

dry skin

vaginal dryness

pain during intimacy

reduced libido

recurrent urinary tract infection

urinary urgency

urinary leakage

SECTION 6: MEDICAL HISTORY

If you have been diagnosed with any of these, please tick:*

high blood pressure

diabetes

high cholesterol

heart disease

stroke

blood clot (deep venous thrombosis or pulmonary embolism?)

migraine

thyroid disease

liver disease

kidney disease

osteoporosis

osteopenia

autoimmune disease

cancer

depression

anxiety disorder

Do you have any medical condition(s) not mentioned above? please provide details*

SECTION 7 : FAMILY HISTORY

If your parent, sibling ,child has ever had any of the conditions listed below, please the box*

breast cancer

ovarian cancer

endometrial cancer

colon cancer

osteoporosis

hip fracture

heart disease

stroke

blood clotting disorders

diabetes

dementia

SECTION 8: MEDICATIONS & SUPPLEMENTS. Please list all current medications in the space below*

If you are currently on any of the drugs listed below, please tick the box.*

menopause hormone therapy

birth control pills

vaginal estrogen

herbal supplements

vitamins

weight-loss medications

calcium

vitamin D

SECTION 9: HORMONE THERAPY SCREENING. If you have been told you have any of the conditions listed below, please tick the box:*

breast cancer

endometrial cancer

unexplained vaginal bleeding

blood clots

stroke

active liver disease

heart attack

SECTION 10: LIFESTYLE & WELLNESS. I will like to know about your smoking, alcohol, exercise, stress and sleep history. How does each apply in your life? Please tell me about each below.*

SECTION 11:SEXUAL HEALTH. Are you currently sexually active?do you have any concerns to share? *

SECTION 12: HEALTH SCREENING HISTORY. Write down the last date you checked each of the following - blood pressure, blood sugar, cholesterol, pap smear/cervical screening , mammogram, bone density scan, colon cancer screening *

SECTION 13. LAB TESTS. If you have any recent test results which you want us to discuss during your session , please write them below. please have them close by during your session.*

SECTION 14: PATIENT GOALS. What are your top 3 goals during this session?list them below in details.*

SECTION 15: ADDITIONAL INFORMATION. If there is anything else you will like me to know, please share below*

CONSENT. I confirm that the information provided above is accurate to the best of my knowledge . I give my consent. Tick the box below if you agree*

I give my consent to this telehealth consultation

Whatsapp number (for quick reminders)*

CLIENT INTAKE FORM

Please fill & submit the form below

© 2026 TEKHI Global for Menopause Health. All Rights Reserved.