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WOMEN'S HEALTH QUESTIONNAIRE
This questionnaire is designed for women who are experiencing menstrual, menopausal and/or gynaecological health concerns. Your answers will assist your practitioner in gaining information about your presentation and assist in the creation of your treatment plan.
HOW TO USE THE QUESTIONNAIRE
When answering, please consider your symptoms from the last 6 months.
Answer all questions in either sections 1-7 if you are menstruating or sections 8-11 if you are menopausal.
If the question is applicable, place a tick in the white box/s for that row.
If there is more than 1 white box per question, place a tick in all the white boxes.
Tick N/A (not applicable) if the question does not relate to your presentation.
Leave any question blank if you are unsure of the answer and discuss this with your practitioner.
EXAMPLE – If you have presented food cravings before your period
11. Do you experience food and/or drink cravings before your periods? SECTIONS 1 – 7: MENSTRUATION
SECTION 1: ENDOMETRIOSIS, FIBROIDS, OVARIAN CYSTS, PCOS
1. Have you been medically diagnosed with endometriosis? 2. Have you been medically diagnosed with uterine fibroids? 3. Have you been medically diagnosed with ovarian cysts? 4. Have you been medically diagnosed with pelvic adhesions or masses? 5. Have you been medically diagnosed with polycystic ovarian syndrome (PCOS)? 6. Do you experience very heavy periods and/or acne? SECTION 2: PREMENSTRUAL SYMPTOMS – the week/s before your period:
7. Do you experience premenstrual mood changes (e.g. frustration, anger, irritability) before 8. Do you have a short temper before your period? 9. Do you feel flat, depressed and/or weepy before your periods? 10. Do you feel cold, tired and/or become pale before your period? TOTALS – PAGE 1
11. Do you experience food and/or drink cravings before your period? 12. Do you experience breast tenderness and/or swelling before your period? 13. Do you experience fluid retention and/or abdominal bloating before your period? 14. Do you experience dul , diffuse headaches before your period? 15. Do you experience migraines or tension headaches before your period? 16. Do you experience changes to your stool before your period (e.g. constipation, diarrhoea)? 17. Are any/all of your premenstrual symptoms worse during times of increased stress? SECTION 3: MENSTRUAL CYCLE PATTERNS
18. Is your menstrual cycle general y shorter than 26 days? 19. Is your menstrual cycle general y longer than 31 days? 20. Do you experience irregular bleeding during your cycle (i.e. mid-cycle spotting)? 21. Do you ever miss periods or have changes in the frequency of your menstrual cycle? 22. Does stress make your menstrual cycle length more irregular? 23. Has chronic stress, increasing age or exercise changed the regularity of your period or stopped your period altogether? SECTION 4: MENSTRUATION
24. Is your period initial y brown in colour, turning to bright red after 1-2 days? 25. Is your period dark in colour, heavy in flow with small clots, up to the size of a 5 cent piece? 26. Is your period heavy with large clots over the size of 10 cent piece? 27. Do your periods last less than 3 days? 28. Do your periods last more than 5 days? 29. Do you experience heavy bleeding during times of stress? TOTALS - PAGE 2
SECTION 5: MENSTRUAL PAIN
30. Do you experience strong pelvic cramping with sharp pains and/or nausea during your 31. Do you experience period pain that is soothed by warmth and pressure, such as hugging a hot water bottle? 32. Do you frequently experience sharp, stabbing period pain that feels worse when you apply pressure and/or warmth to the area, but feels better if you lie or sit still? 33. Do you frequently experience diarrhoea or loose stools at the onset of your period? 34. Do you frequently faint or vomit at the onset of your period? 35. Do all of your menstrual symptoms improve if you are relaxed and not under stress? 36. Do you experience pain during intercourse, during exercise or during the passing of stool? SECTION 6: MID-CYCLE (OVULATION) SYMPTOMS
37. Do you experience sharp, stabbing pains mid-cycle which is worse when you apply 38. Do you experience vaginal dryness? 39. Are you trying to conceive or have experienced difficulty conceiving? 40. Are you over 35 years of age and trying to conceive? 41. Have you experienced rapid weight loss recently or are you underweight? SECTION 7: AFTER MENSTRUATION
42. Do you feel exhausted, pale and fatigued after your period? 43. Do you frequently experience lower back pain following your period? TOTALS - PAGE 3
Add to TOTALS - PAGE 1 Add to TOTALS - PAGE 2 TOTALS FOR SECTIONS 1-7: MENSTRUATION
SECTIONS 8 – 11: MENOPAUSE
SECTION 8: MENOPAUSAL PATIENTS ONLY – HOT FLUSHES
44. Do you have moderate to severe hot flushes and sweats during the night? 45. Do you flush in the face? 46. Do you have mild hot flushes during the day and night? 47. Do you have moderate to severe hot flushes throughout the day? SECTION 9: MENOPAUSAL PATIENTS ONLY – MOOD & MIND SYMPTOMS
48. Do you frequently have low mood, are teary and/or sad? 49. Do you experience mood swings, with irritability and anger? 50. Do you experience anxiety, excessive worry or feel panicky? 51. Do you feel tired and burnt out with low reserves? 52. Do you feel exhausted from chronic stress and overwork? 53. Do you experience feeling "fuzzy in the head" at times? 54. Do you, or have you, experienced extended periods of low mood? 55. Do you crave coffee, alcohol or cigarettes to get through the day? SECTION 10: MENOPAUSAL PATIENTS ONLY – SLEEP & INSOMNIA
56. Do you have trouble fal ing asleep at night? 57. Do you wake during the night with hot flushes and sweats? 58. Do you frequently wake between 1-3 am? 59. Do you frequently wake too early in the mornings? TOTALS - PAGE 4
SECTION 11: MENOPAUSAL PATIENTS ONLY – OTHER BODY SYMPTOMS
60. Do you experience with vaginal dryness? 61. Has your libido (sex drive) changed significantly over the recent months or years? 62. Do you experience a weak, aching back and/or weak knees? 63. Are you prone to constipation? 64. Are you prone to alternating constipation & diarrhoea? 65. Do you experience heat and/or dryness in your palms and soles? 66. Did/do you suffer with an irritable premenstrual period? 67. Are all of your menopausal symptoms worse when you are under stress? TOTALS - PAGE 5
Add to TOTALS - PAGE 4 TOTALS FOR SECTIONS 8-11: MENOPAUSE
WOMEN'S HEALTH QUESTIONNAIRE
PRACTITIONER SCORING SHEET
SECTIONS 1 – 7
Transfer the totals on page 3 into the ‘score' column below.
Rank each section based on the score in descending order, i.e. ‘1' is the top score, ‘2' is the second-highest A score of 8 or more indicates a remedy may be appropriate. The highest score indicates the primary remedy and in some cases, more than one remedy may be appropriate.
If the top scores are quite close together, review the questions in those sections. The recommended section to take priority is that which addresses the most relevant clinical concerns for your patient. Bupleurum Complex Angelica and Vitex for Cinnamon Complex Shatavari for Nervous Tension for Pelvic & Irritability* Menstrual Relief* Congestion* *These products are contraindicated during pregnancy. These products are contraindicated or cautioned during lactation.
SECTIONS 8 – 11
MENOPAUSE
Follow the instructions above to complete the score sheet below.
Any score of 5 or over indicates a remedy that may be appropriate, with the highest score being the primary Bupleurum Complex for Nervous Tension & Rehmannia Hot Flush# Natural Menopausal #These formulas are contraindicated in oestrogen-dependant cancers. ADDITIONAL CONSIDERATIONS
To improve 2:16 hydroxyoestrogen ratio: Healthy Hormone Balance and/or Indole-3-Carbinol: Oestrogen
Treatment Protocols: For further information on treating hormonal conditions, also refer to treatment protocols
for dysmenorrhoea, menorrhagia, endometriosis, polycystic ovarian syndrome, uterine fibroids, and menopause.

Source: http://www.transitiontohealth.net/download/i/mark_dl/u/1358025/3869762/WHQ%20-%20Metagenics.pdf