FREE MENOPAUSE HEALTH STATUS ASSESSMENT

Name *

Age*

Your email*

Choose all that apply to you*

Hot flushes

Palpitations

Night Sweats

Mood swings

Always tired

Overweight

Low Libido

Painful sex

Irregular periods

No periods

Low self esteem

Depression

Suicidal thoughts

Brain fog

Forgetfulness

I have primary ovarian insufficiency

My womb has been removed

bone pains, joint pains

I have never heard about the menopause

I have little knowledge about menopause

I want to learn more about the menopause

I never knew that menopause needs any health care, support and follow up by a menopause consultant

I do not exercise regularly

I exercise regularly

I eat healthy all the time

I eat healthy sometimes

I have no idea what a healthy diet is

I have no idea what regular exercise means

I think I am maybe premenopausal

I think may be perimenopausal

I think I maybe in postmenopausal

I have no idea about menopause stages

I smoke (even if only sometimes, take this option)

I drink alcohol (even if only sometimes, take this option)

I take coffee (even if it is sometimes, still take this option)

i take calcium supplements

I will like to book an appointment with a menopause consultant at TEKHI GLOABL FOR MENOPAUSE HEALTH

I have diabetes

I have hypertension

I have a history of stroke

I have a history of cancer, a family history of cance

I have a history of a fractured bone

I have a history of other medical conditions not mentioned here

I have done several imaging tests like x-rays, CT scan, MRI (If you have done any of these more than twice please take this option)

I think i am overweight

I think I am normal weight

I think i am underweight

I think i am obese

I don't know my weight.

My spouse/partner is supportive with regards to the symptoms I face in my aging journey

My spouse/partner is not supportive with regards to the symptoms I face in my aging journey

My family and close friends are supportive with regards to my symptoms in my aging journey

My family and close friends are not supportive with regards to my symptoms in my aging journey

My colleagues, employer and workplace are supportive with regards to my symptoms in my aging journey

My colleagues, employer and workplace are not supportive with regards to my symptoms in my aging journey

I create special time to rest and relax every week

I do not create time to rest and relax every week

My spouse/partner has no idea about the changes and possible symptoms and challenges which come with aging as a woman

My spouse/partner has some knowledge about the changes and possible symptoms and challenges which come with aging as a woman

My family and close friends have no idea about the changes and possible symptoms and challenges which come with aging as a woman

My family and close friends have some knowledge about the changes and possible symptoms and challenges which come with aging as a woman

My employer and colleagues have no idea about the changes and possible symptoms and challenges which come with aging as a woman

My employer and colleagues have some knowledge about the changes and possible symptoms and difficulties which come with aging as a woman

I have issues currently stressing me up

I have no issues stressing me up

I did not even know that I have to create time to rest

I know that i have to create time to rest but i have not been doing so

Country of residence*

Your facilitator's code (If applicable to you)

How did you learn about TEKHI GLOBAL FOR MENOPAUSE HEALTH? *

Height*

Most recent value of your waist circumference (in cm )

Three most recent values of your blood pressure (taken within the last three months - If you have this information, please write)

Weight (in kg)*

KNOW YOUR CURRENT RISK FOR CARDIOVASCULAR DISEASE, OSTEOPOROSIS, TYPE 2 DIABETES, STROKE, DEMENTIA AND OTHER LIFE-THREATENING HEALTH COMPLICATIONS, AS YOU NAVIGATE THROUGH YOUR AGING JOURNEY