HealthRX.com · Printable question sheet
Perimenopause hot flash and vaginal symptom visit sheet
Fill this in by hand before a visit about hormone therapy, non-hormonal hot flash drugs or vaginal symptom treatment. Bring it to your prescriber or pharmacist, or keep it at home to track symptoms between visits.
Your stage and bleeding history
Write what you know. Leave blank if unsure.
Recent change in cycle lengthDescribe how cycles have shifted
Any bleeding or spotting since your last periodWrite dates and how much
Uterus statusIntact, removed or ablated, and when
Current vaginal symptomsDryness, burning, pain or urinary changes
Before the visit
Gather these items so the visit covers your full picture.
- List every prescription, over-the-counter product, supplement and herbal remedy you take
- Bring any liver test results if a non-hormonal hot flash drug has been discussed
- Note any family history of breast cancer, blood clots or stroke
- Bring your symptom log from the past few weeks
- Check with your pharmacist which current medicines may interact with a new treatment
- Confirm whether your insurer covers the drug and what the prior authorization steps are
- Write down any bleeding after menopause to report at the visit
Questions to ask at the visit
- Am I within the age and time-since-onset window where starting hormone therapy is considered?
- Would a transdermal product be a better route for my clot risk than an oral one?
- Does my uterus mean I need a progestogen added to estrogen?
- Would a low-dose vaginal product be enough if my symptoms are only vaginal?
- Which non-hormonal option fits my other medicines, and what liver tests would I need?
- If I take tamoxifen, would paroxetine be a safe choice for hot flashes?
- What schedule of reassessment will you use to decide whether to continue treatment?
- Are compounded bioidentical hormones ever a choice in my case, given FDA-approved options?
Hot flash and sleep log
Track each day or week between visits and bring this page.
| Date | Hot flashes | Night sweats | Sleep quality | Notes |
|---|---|---|---|---|
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.