Medical details
Tick here if you have private medical insurance
Tick here if you would like your GP to receive a copy of your results letter should they be abnormal and further investigations are required
Are you of Jewish ancestry? *
Please select...
No
Yes
How old were you when you had your first period? *
Please select...
Never menstruated
8 Yrs 9 Yrs 10 Yrs 11 Yrs 12 Yrs 13 Yrs 14 Yrs 15 Yrs 16 Yrs 17 Yrs 18 Yrs 19 Yrs 20 Yrs
Do you have any children
Please select...
No
Yes
Have you been through the menopause? *
Please select...
Currently perimenopausal No Yes
If yes, how old were you at menopause? *
N/A
30 Yrs 31 Yrs 32 Yrs 33 Yrs 34 Yrs 35 Yrs 36 Yrs 37 Yrs 38 Yrs 39 Yrs 40 Yrs 41 Yrs 42 Yrs 43 Yrs 44 Yrs 45 Yrs 46 Yrs 47 Yrs 48 Yrs 49 Yrs 50 Yrs 51 Yrs 52 Yrs 53 Yrs 54 Yrs 55 Yrs 56 Yrs 57 Yrs 58 Yrs 59 Yrs 60 Yrs 61 Yrs 62 Yrs 63 Yrs 64 Yrs 65 Yrs 66 Yrs 67 Yrs 68 Yrs 69 Yrs 70 Yrs
Do you or have you ever used HRT? *
Please select...
No
Yes
Started using:
1 2 3 4 5 6 7 8 9 10 11 12
1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040
Date last used:
1 2 3 4 5 6 7 8 9 10 11 12
1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040
What type? *
Unknown Oestrogen only Combined
Have you had a breast biopsy in the past? *
Please select...
No
Yes
Were any of the following identified? *
None Hyperplasia Atypical hyperplasia LCIS (pre-cancerous cells) Unknown
Have you ever been diagnosed with any type of cancer *
Have you ever been diagnosed with any type of cancer *
Have you ever been diagnosed with any cardiac related condition *
Please select...
No
Yes
What type of cancer? *
What was the condition *
If yes, at what age? *
N/A
20 Yrs 21 Yrs 22 Yrs 23 Yrs 24 Yrs 25 Yrs 26 Yrs 27 Yrs 28 Yrs 29 Yrs 30 Yrs 31 Yrs 32 Yrs 33 Yrs 34 Yrs 35 Yrs 36 Yrs 37 Yrs 38 Yrs 39 Yrs 40 Yrs 41 Yrs 42 Yrs 43 Yrs 44 Yrs 45 Yrs 46 Yrs 47 Yrs 48 Yrs 49 Yrs 50 Yrs 51 Yrs 52 Yrs 53 Yrs 54 Yrs 55 Yrs 56 Yrs 57 Yrs 58 Yrs 59 Yrs 60 Yrs 61 Yrs 62 Yrs 63 Yrs 64 Yrs 65 Yrs 66 Yrs 67 Yrs 68 Yrs 69 Yrs 70 Yrs 71 Yrs 72 Yrs 73 Yrs 74 Yrs 75 Yrs 76 Yrs 77 Yrs 78 Yrs 79 Yrs 80 Yrs 81 Yrs 82 Yrs 83 Yrs 84 Yrs 85 Yrs 86 Yrs 87 Yrs 88 Yrs 89 Yrs 90 Yrs 91 Yrs 92 Yrs 93 Yrs 94 Yrs 95 Yrs 96 Yrs 97 Yrs 98 Yrs 99 Yrs 100 Yrs
What treatment have you had/are having? *
Questions marked with * are mandatory
