Menopause

Please state your gender

This refers to your biological gender

Male

Female

Date of Birth

Use the calendar to select your date of birth.

Have you suffered any negative effects as a result of consuming Indivina?

Yes

No

For which duration have you used Livial Tablet?

Who gave you the Livial Tablet first?
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Is Novofem something you are using right now?
if so, have you noticed any improvements on your symptoms?

Yes

No

Have you suffered any negative effects as a result of consuming Novofem?

Yes

No

For which duration have you used Novofem?

Who gave you the Novofem first?
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Is Oestrogel something you are using right now?
if so, have you noticed any improvements on your symptoms?

Yes

No

Have you suffered any negative effects as a result of consuming Oestrogel?

Yes

No

For which duration have you used Oestrogel?

Who gave you the Oestrogel first?
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Is Premarin 0.65mg Tablet something you are using right now?
if so, have you noticed any improvements on your symptoms?

Yes

No

Have you suffered any negative effects as a result of consuming Premarin Tablet ?

Yes

No

Have you suffered any negative effects as a result of consuming Livial Tablet?

Yes

No

Is Livial Tablet something you are using right now?
if so, have you noticed any improvements on your symptoms?

Yes

No

Who gave you the Lenzetto first?
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For which duration have you used Indivina?

Who gave you the Indivina first?
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Have twelve months already lapsed since you experienced your last period?

Yes

No

For which duration have you used Kliofem Tablet?

Who gave you the Kliofem Tablet first?
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Is Kliovance Tablet something you are using right now?
if so, have you noticed any improvements on your symptoms?

Yes

No

Have you suffered any negative effects as a result of consuming Kliovance Tablet?

Yes

No

For which duration have you used Kliovance Tablet?

Who gave you the KliovanceTablet first?
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Is Lenzetto something you are using right now?
if so, have you noticed any improvements on your symptoms?

Yes

No

Have you suffered any negative effects as a result of consuming Lenzetto?

Yes

No

For which duration have you used Lenzetto?

For which duration have you used Premarin Tablet ?

Who gave you the Premarin Tablet first?
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Who gave you the Trisequens?
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Are you using any ostrogen at the moment?
If you are, please indicate which one (this may be an oral tablet, a gel, or a patch).
Is there a reason you aren't taking an oestrogen as well?

Yes

No

Is Utrogestan something you are using right now?
if so, have you noticed any improvements on your symptoms?

Yes

No

Have you suffered any negative effects as a result of consuming Utrogestan?
If so, kindly describe the symptoms you have suffered.

Yes

No

For which duration have you used Utrogestan ?

Who gave you the Utrogestan?
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Is Utrogestan your preferred contraceptive?

Yes

No

Have you placed a Mirena coil in right now?

Yes

No

Do you experience any of the following?
You are under medication or receiving supplements
You have a medical condition
You are currently breastfeeding or pregnant

Yes

No

Is Zumenon something you are using right now?
if so, have you noticed any improvements on your symptoms?

Yes

No

Have you suffered any negative effects as a result of consuming Zumenon?
If so, kindly describe the symptoms you have suffered.

Yes

No

For which duration have you used Zumenon ?

For which duration have you used Trisequens ?

Have you suffered any negative effects as a result of consuming Trisequens?
If so, kindly describe the symptoms you have suffered.

Yes

No

Is Trisequens something you are using right now?
if so, have you noticed any improvements on your symptoms?

Yes

No

Is Premique Low Dose Tablets something you are using right now?
if so, have you noticed any improvements on your symptoms?

Yes

No

Have you suffered any negative effects as a result of consuming Premique Low Dose Tablets ?
If so, kindly describe the symptoms you have suffered.

Yes

No

For which duration have you used Premique Low Dose Tablets ?

Who gave you the Premique Low Dose Tablets?
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Is Progynova Tablet something you are using right now?
if so, have you noticed any improvements on your symptoms?

Yes

No

Have you suffered any negative effects as a result of consuming Progynova Tablet ?
If so, kindly describe the symptoms you have suffered.

Yes

No

For which duration have you used Progynova Tablet ?

Who gave you the Progynova Tablet?
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Is Sandrena Gel something you are using right now?
if so, have you noticed any improvements on your symptoms?

Yes

No

Have you suffered any negative effects as a result of consuming Sandrena Gel ?
If so, kindly describe the symptoms you have suffered.

Yes

No

For which duration have you used Sandrena Gel ?

Who gave you the Sandrena Gel?
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Who gave you the Zumenon?
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Is Indivina something you are using right now?
if so, have you noticed any improvements on your symptoms?

Yes

No

Is menopause something you are experiencing at the moment?

Yes

No

Are you aware of and agree with the following:
Breast cancer risk is enhanced when combined HRT is used.
Hormone replacement therapy (HRT) raises the risk of womb cancer.
Blood clots are more likely after taking HRT tablets.
The use of hormone replacement therapy (HRT) raises the risk of cardiovascular disease (if started at age 60 or over).
HRT drugs should not be taken for more than 5 years, according to the manufacturers, due to a lack of research on their hazards after that time.
The majority of hazards associated with HRT use are minor and revert to baseline after HRT is discontinued. More information on the advantages and hazards of HRT can be found here.

Yes

No

Did you know that that HRT products for gender transformation are not available from us?
Gender reassignment is a difficult procedure that requires a face-to-face consultation with a doctor and cannot be ordered over the internet.

Yes

No

Are you aware that:
You should use the smallest dose of HRT possible for the shortest duration possible.
If your doctor has instructed you to discontinue using HRT, you should stop immediately.
You should check your breasts for lumps on a regular basis. Instructions can be found here.

Yes

No

Is Elleste Duet 2mg tablet something you are using right now?
if so, have you noticed any improvements on your symptoms?

Yes

No

Have you suffered any negative effects as a result of consuming Elleste Duet?

Yes

No

For which duration have you used Elleste Duet?

Who gave you the Elleste Duet 2mg tablets first?
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Do you have a history of using any other HRT treatments?
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Have six months already lapsed since you experienced your last period?

Yes

No

Are you on any of the following medication?
Antibiotics.
Antihistamines such as stemizole or terfenadine.
Cisapride for stomach discomfort.
Quinidine for circulatory problems.
Pimozide for schizophrenia.

Yes

No

Did you know that once you suffer any of the following symptoms, you should stop taking HRT and consult a doctor:
Skin discoloration or yellowing of the whites of your eyes (jaundice).

A significant increase in your blood pressure symptoms which can include headache, dizziness & tiredness.
Migraine-like headaches, with or without vision disturbance, that occur for the first time.
You have chest pain that has moved to your arm or neck.
Blood clot symptoms such as painful swelling and redness of the legs, sudden chest pain or difficulty breathing.

Yes

No

Can you relate to any of the following statements?
You have or have had stomach or duodenal ulcers, as well as stomach or intestinal bleeding in the past.
Your doctor has ever told you that your kidney function is less than 100 percent.
You have previously suffered a terrible reaction to aspirin, ibuprofen, or other nonsteroidal anti-inflammatory drugs (NSAIDs).
You want to use Ibuprofen Gel on skin that is fractured, injured, diseased, or infected.

Yes

No

Do you or anyone in your family have a history of having:
Clots in the blood
Breast, ovary, cervix, or womb/uterus cancer
Breast issues
Thyroid issues

Yes

No

Have you been experiencing any of the following symptoms?
Vaginal bleeding that is abnormal.
Gallstones.
Diabetes.
Migraines.
Blood pressure that is too high.
A blood clotting disease, often known as a blot clot.
Porphyria
Breast issues

Yes

No

If you know your blood pressure, do you frequent your doctor to have it checked and monitord?

Yes

No

Do you recall the first time you experienced menopause symptoms?

How long has it been since you had your last period?

Have you had your uterus removed?
If not, do you consume a progestogen (kindly specify)? This could be a Mirena coil or an oral tablet like norethisterone.

Yes

No

Kindly identify the symptoms that you are experiencing or would experience if you did not take HRT:
You can choose more than one option

Do you know of any reason why you shouldn't use HRT, or have you been previously prevented from using it by your doctor?

Yes

No

Do you consent to the following routine checks:
Check your blood pressure and take a blood test.
Smear of the cervix.
Mammogram/breast ultrasonography screening.

Yes

No

Do you remember the last time you had a gynecological exam or a cervical smear test?

Do you remember the last time you had a mammogram or a breast examination?

Do you remember the last time your blood pressure was checked by your doctor?

Do you smoke?

If you do, please write how many cigarettes you smoke per day. Or, if you vape, please tell us about this.

Yes

No

Please share your Height (cm) and Weight (Kg)

Height should be above 1 ft 10 inches

Do you know if your blood pressure is Low, Normal or High? Please write LOW, NORMAL or HIGH

Use the following as a guide:

Low = Under 90/60
Normal = Between 90/60 and 140/90
High = Over 140/90

What is your biological gender?

Please select your option

Male

Female

If female or transmale, are you currently pregnant, breastfeeding or planning to do so?

Please select your option

Presently Pregnant

Presently Breastfeeding

Planning on getting pregnant

Planning on Becoming Pregnant

Neither Pregnant nor Breastfeeding

Who gave you the first Evorel patch?
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Have eighteen months already lapsed since you experienced your last period?

Yes

No

Is Evorel Sequi something you are using right now?
if so, have you noticed any improvements on your symptoms?

Yes

No

Have you suffered any negative effects as a result of consuming Evorel Sequi?

Yes

No

Who gave you the first Evorel Sequi patch?
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Is FemSeven something you are using right now?
if so, have you noticed any improvements on your symptoms?

Yes

No

Have you suffered any negative effects as a result of consuming FemSeven ?

Yes

No

For which duration have you used FemSeven ?

Who gave you the first FemSeven ?
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Is Femoston something you are using right now?
if so, have you noticed any improvements on your symptoms?

Yes

No

Have you suffered any negative effects as a result of consuming Femoston?

Yes

No

For which duration have you used Femoston?

For which duration have you used Evorel?

Have you suffered any negative effects as a result of consuming Evorel?

Yes

No

Is Evorel something you are using right now?
if so, have you noticed any improvements on your symptoms?

Yes

No

Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.

Yes

No

Can you relate to any of the following?
You have an underlying medical condition
You've been through a major surgical procedure
You have allergic reactions
You have cardiovascular conditions or might have had suffered a stroke
You suffer from a low liver or kidney function

Yes

No

Can we share this information with your General practitioner?

Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advise you share this treatment with your doctor for him/her to update your medical records.

Yes

No

Is Elleste Solo tablet something you are using right now?
if so, have you noticed any improvements on your symptoms?

Yes

No

Have you suffered any negative effects as a result of consuming Elleste Solo?

Yes

No

For which duration have you used Elleste Solo?

Who gave you the Elleste Solo tablets first?
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Is Estradot something you are using right now?
if so, have you noticed any improvements on your symptoms?
If not, how did you know this treatment was suitable for you?

Yes

No

Have you suffered any negative effects as a result of consuming Estradot?

Yes

No

For which duration have you used Estradot?

Who gave you Estradot first?
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Did you know that:
A healthcare practitioner should assess any acute injuries.
You should see your doctor about chronic pain at least once a year.

Yes

No

Who gave you the Femoston first?
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