Menopause Impact Tool

Patient Name:

Date of Birth : / /  

THIS SECTION TO BE COMPLETED BY HEALTHCARE PROFESSIONAL

Date:

Patient Time in: Patient Time Out:

Past Hysterectomy :   Yes No

Menopausal :   Yes No

Patient Instructions: Please answer the questions below prior to meeting with your healthcare professional who will review the completed questionnaire during your office visit.

RATING SCALE:   1 - Not at all or rarely    2 - A little or moderately        3 - Regularly or frequently

ASSESSMENT OF VASOMOTOR SYMPTOMS

In the last month, to what extent have you been bothered by the following symptoms? Please rate each symptom from 1 to 3 (refer to above scale and click on your response).  Then, place a "√" in ONE of the boxes by clicking on box to indicate which ONE symptom is most bothersome to you, or most disrupts your daily life.

Hot flashes

1 2 3

Night sweats or chills

 1 2 3

Sleep disturbance

 1 2 3

Joint pain or stiffness

 1 2 3

Fatigue

 1 2 3

   To what extent have these symptoms negatively impacted the following (refer to above scale and click on your response)?

Feelings about yourself

 1 2 3

Relationships

1 2 3

Work 

 1 2 3

Total Vasomotor Symptoms Assessment Score

ASSESSMENT OF SEXUAL HEALTH

In the last month, to what extent have you been bothered by the following symptoms? Please rate each symptom from 1 to 3 (refer to above scale and click on your response).  Then, place a "√" in ONE of the boxes by clicking on box  to indicate which ONE symptom is most bothersome to you, or most disrupts your daily life.

Genital dryness, pain and/or burning

1 2 3

Pain during sexual activity       

1 2 3

Decreased sexual desire

 1 2 3

Decreased sexual response

 1 2 3

Decreased sexual frequency 

1 2 3

   To what extent have these symptoms negatively impacted the following (refer to above scale and click on your response)?

Feelings about yourself

 1 2 3

Relationships

1 2 3

Work

 1 2 3

Total Sexual Health  Assessment Score

ASSESSMENT OF PSYCHOLOGICAL SYMPTOMS

In the last month, to what extent have you been bothered by the following symptoms? Please rate each symptom from 1 to 3 (refer to above scale and click on your response).  Then, place a "√" in ONE of the boxes by clicking on box  to indicate which ONE symptom is most bothersome to you, or most disrupts your daily life.

Anxiety  

1 2 3

Irritability        

1 2 3

Sadness

1 2 3

Difficulty concentrating

 1 2 3

   To what extent have these symptoms negatively impacted the following (refer to above scale and click on your response)?

Feelings about yourself

 1 2 3

Relationships

1 2 3

Work

 1 2 3

Total Psychological Symptoms  Assessment Score.
  Total  Score for Menopause Symptoms and Impact Assessment (please add Total Assessment Scores from above for final total).

TREATMENT ASSESSMENT

  Please choose the statement that applies to you (click on the most appropriate response).

"I'd like to try hormone therapy for the treatment of my menopausal symptoms."
"I'd consider taking hormone therapy for the treatment of my menopausal symptoms, but I would first like to learn more."
"I've taken hormone therapy in the past for the treatment of my menopausal symptoms, but I didn't like it."
"I'll never take hormone therapy for the treatment of my menopausal symptoms."
NOTE TO HEALTHCARE PROFESSIONAL:

Important: In addition to the above, the patient's family and medical history should be reviewed and assessed in order to determine if the patient is a candidate for hormone therapy. Some, but not all medical conditions important to identify include: hysterectomy, breast cancer, stroke, osteoporosis, venous thromboembolism (VTE), coronary artery disease (CAD) or hypertension, dementia, colon cancer.

Suggestion: It is suggested that the assessment questionnaire be completed again 3 − 6 months after initiating treatment to determine treatment adherence and effectiveness.