Consultation - Mentor Pharmacy

Menopause

Please fill out the form below so that our clinicians can determine if the treatment will be suitable for you to take.

1 About Your Health

Your health and safety are our top priorities. Please provide accurate and complete information during your consultation so we can recommend the most appropriate treatment for you.

Question 1:Do you have any known allergies?

Question 2:Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)

If yes, please detail them here, otherwise please type N/A

Question 3:Are you currently taking any medications?

If yes, please detail them here, otherwise please type N/A

Question 4:Have you had any surgeries in the past year?

If yes, please detail them here, otherwise please type N/A

Question 5:Do you smoke?

Question 6:Do you consume alcohol?

If yes, how much a day/weekly?

Question 7:What is your typical diet like? (e.g., balanced, high-fat, spicy foods)

Question 8:How often do you exercise? (e.g., daily, weekly, rarely, never)

2 About Your Condition

Please provide accurate and honest details during your consultation. This helps us offer the safest and most effective treatment for you.

Question 1:How long have you been experiencing menopause symptoms?

Please provide more information here

Question 2:What symptoms are you currently experiencing? (e.g., hot flashes, night sweats, mood swings, vaginal dryness, sleep disturbances)

Please provide more detail here

Question 3:How severe are your symptoms on a scale of 1 to 10 (1 being mild and 10 being severe)?

Please provide more information here

Question 4:Have your symptoms interfered with your daily activities or quality of life?

Question 5:Have you been diagnosed with menopause by a healthcare professional?

Yes

Question 6:Have you had any tests to confirm the diagnosis? (e.g., blood tests for hormone levels)

Question 7:Have you been prescribed medication for menopause symptoms before?

Question 8:Are you currently taking any medication for menopause symptoms?

Question 9:Have you experienced any side effects from your current or past menopause medications?

Question 10:Have you tried any non-medication treatments for menopause symptoms? (e.g., lifestyle changes, dietary supplements, herbal remedies)

Question 11:Have you used over-the-counter treatments for menopause symptoms?

3 The Agreement and Consent

Please read the Agreement and Consent statements carefully during your consultation. They contain important information to help you stay informed and safe throughout your treatment.

Question 1:Understanding of Risks

I have been informed about the potential side effects and interactions of the prescribed medication for Menopause.

Question 2:Medical Guidance

I agree to consult with my healthcare provider before starting any new medication.

I understand that the information provided in this assessment will be reviewed by a licensed pharmacist before my order is processed.

Question 3:Consent to Share Information

I consent to my personal and medical information being used to assess my suitability for the prescribed medication.

I understand that my information will be kept confidential and used solely for the purpose of this assessment.

Question 4:Confirmation

I confirm that the information provided in this assessment is accurate and complete to the best of my knowledge.

I understand that providing false information may result in my order being cancelled and may have health implications.

1 About Your Health
2 About Your Condition
3 The Agreement and Consent

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Acne

Asthma

Contraceptives

Eczema and Dermatitis

Erectile Dysfunction

Hay Fever

Menopause

Shingles

Sinusitis

Urinary Tract Infection (UTI)

Ear Wax Removal

Private Blood Tests

Assessment for Menopause

Menopause

1 About Your Health

Question 1:Do you have any known allergies?

Yes

Question 2:Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)

Yes

Question 3:Are you currently taking any medications?

Yes

Question 4:Have you had any surgeries in the past year?

Yes

Question 5:Do you smoke?

Yes

Question 6:Do you consume alcohol?

Yes

Question 7:What is your typical diet like? (e.g., balanced, high-fat, spicy foods)

Yes

Question 8:How often do you exercise? (e.g., daily, weekly, rarely, never)

Yes

2 About Your Condition

Question 1:How long have you been experiencing menopause symptoms?

Question 2:What symptoms are you currently experiencing? (e.g., hot flashes, night sweats, mood swings, vaginal dryness, sleep disturbances)

Question 3:How severe are your symptoms on a scale of 1 to 10 (1 being mild and 10 being severe)?

Question 4:Have your symptoms interfered with your daily activities or quality of life?

Yes

Question 5:Have you been diagnosed with menopause by a healthcare professional?

Question 6:Have you had any tests to confirm the diagnosis? (e.g., blood tests for hormone levels)

Yes

Question 7:Have you been prescribed medication for menopause symptoms before?

Yes

Question 8:Are you currently taking any medication for menopause symptoms?

Yes

Question 9:Have you experienced any side effects from your current or past menopause medications?

Yes

Question 10:Have you tried any non-medication treatments for menopause symptoms? (e.g., lifestyle changes, dietary supplements, herbal remedies)

Yes

Question 11:Have you used over-the-counter treatments for menopause symptoms?

Yes

3 The Agreement and Consent

Question 1:Understanding of Risks

Question 2:Medical Guidance

Question 3:Consent to Share Information

Question 4:Confirmation

Assessment Progress

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