Jubiley | Hormone Therapy Screening

First, your patient details.

These will appear at the top of the report your clinician receives.

Full name

Date of birth

Privacy: Your name, date of birth, and health answers will be included in the QR code. Anyone who obtains the code may read them. Only show it to your treating healthcare professional; do not photograph or send it to others.

Let's start with how you feel.

Think about your symptoms over the past seven days.

How often have you had hot flashes?

How severe are your hot flashes, from 0 to 10?

0 · Not bothersome10 · Extremely severe

5

Have you experienced night sweats?

NoYes

How much have symptoms disrupted your sleep?

A few questions about your health.

These conditions can affect whether systemic menopausal hormone therapy is appropriate. Please answer as accurately as you can.

Finally, some background.

These factors may change the discussion about treatment choices and risks.

Which age range are you in?

How long has it been since your last natural period?Select the best answer if you have had a hysterectomy or surgery affecting menopause.

Do you have a uterus?

YesNoNot sure

A clearer path to the right conversation.

First, your patient details.

Let's start with how you feel.

A few questions about your health.

Finally, some background.

Your screening is complete.