# Menopause symptom record for your GP (printable)

Her Vitals, hervitals.co.uk. Information only, not medical advice. Not a substitute for a registered clinician.

This is our own neutral symptom record, built around the symptom domains that validated menopause questionnaires use. It is NOT the Greene Climacteric Scale or the Menopause Rating Scale and it does not produce a score. Those instruments are copyrighted and are meant to be scored by a clinician; if your GP or clinic uses one, they will give it to you. Use this sheet to record what you are experiencing so the appointment starts from a clear picture. Rate each symptom 0 to 3.

0 = not at all   1 = a little   2 = quite a bit   3 = extremely

Name: ____________________   Date: ____________

## Psychological (mood and anxiety)
- Feeling anxious or on edge: 0  1  2  3
- Panicky feelings: 0  1  2  3
- Difficulty concentrating: 0  1  2  3
- Feeling tired or lacking energy: 0  1  2  3
- Loss of interest in things: 0  1  2  3
- Feeling low or unhappy: 0  1  2  3
- Irritability: 0  1  2  3

## Somatic (physical)
- Headaches: 0  1  2  3
- Muscle or joint aches: 0  1  2  3
- Difficulty sleeping: 0  1  2  3
- Palpitations (noticeable heartbeat): 0  1  2  3
- Dizziness or faintness: 0  1  2  3
- Skin crawling or tingling sensations: 0  1  2  3

## Vasomotor (temperature)
- Hot flushes: 0  1  2  3
- Night sweats or sweating: 0  1  2  3

## Urogenital and sexual
- Vaginal dryness or discomfort: 0  1  2  3
- Discomfort or pain during sex: 0  1  2  3
- Reduced interest in sex: 0  1  2  3
- Bladder problems (urgency, frequency, leaking): 0  1  2  3

## Notes for the appointment
- Which symptoms bother you most: ____________________
- How long they have been going on: ____________________
- How they affect work, sleep and relationships: ____________________
- Your periods now (regular, irregular, stopped, and when): ____________________

## About the validated instruments (for reference)
- Greene Climacteric Scale: a 21-item questionnaire covering psychological (anxiety and depressed mood), somatic, vasomotor and sexual symptoms, each rated 0 to 3. Original reference: Greene JG. Constructing a standard climacteric scale. Maturitas 1998;29(1):25-31.
- Menopause Rating Scale (MRS): an 11-item questionnaire with three subscales, somato-vegetative, psychological and urogenital, each item rated 0 to 4. See Heinemann K et al., Health and Quality of Life Outcomes 2004. https://hqlo.biomedcentral.com/articles/10.1186/1477-7525-2-67

Sources:
- NICE guideline NG23, Menopause: identification and management. https://www.nice.org.uk/guidance/ng23
- NHS, Menopause and perimenopause symptoms. https://www.nhs.uk/conditions/menopause-and-perimenopause/symptoms/

Information only, not medical advice. This record does not diagnose anything.