MENOPAUSE SCREENING
Age: BP Height: Height
at 18: Weight: Weight
at 18:
BMI: Date of last menses/HRT?
Family history: CAD / DM / Cancer- colon, breast, ovarian, uterine, cervical / OP
PMH:
Past surgical history:
Presence of symptoms:
Hot flashes
Vaginal dryness
Irritability
Anxiety
Forgetful / distracted
Weight gain
Changes in skin
Dietary review include. Number of dairy products serving/day: Calcium/ Vitamin D Supplement:
Exercise review
Vertebral frac ture: yes or no
Any fracture since age 45?
Current smoking: how many packs/day
Past history of smoking:
Alcohol/caffeine consumption servings
Current medications include: Steroids? Thyroid? Anti seizure?
Heart disease:
Angina / Stroke review –
BP monitoring
Cholesterol screening
Diabetes
Mental status
Depression /anxiety screening
Yearly Mammogram Pap smear
Vaginal bleeding
Colon cancer - Hemocult / Sigmoidoscopy / Colonoscopy
Caregiver issues
BMI: Date of last menses/HRT?
Family history: CAD / DM / Cancer- colon, breast, ovarian, uterine, cervical / OP
PMH:
Past surgical history:
Presence of symptoms:
Hot flashes
Vaginal dryness
Irritability
Anxiety
Forgetful / distracted
Weight gain
Changes in skin
Dietary review include. Number of dairy products serving/day: Calcium/ Vitamin D Supplement:
Exercise review
Vertebral frac ture: yes or no
Any fracture since age 45?
Current smoking: how many packs/day
Past history of smoking:
Alcohol/caffeine consumption servings
Current medications include: Steroids? Thyroid? Anti seizure?
Heart disease:
Angina / Stroke review –
BP monitoring
Cholesterol screening
Diabetes
Mental status
Depression /anxiety screening
Yearly Mammogram Pap smear
Vaginal bleeding
Colon cancer - Hemocult / Sigmoidoscopy / Colonoscopy
Caregiver issues