Visit prep sheet

Walk in prepared

Appointments are short. Fill this in, print it or save it as a PDF, and hand it to your provider. It stays on your device only.

Your answers are saved in this browser so you can come back to them. "Clear my answers" removes them from this device.

This is not medical advice. It's a note-taking aid — your provider decides what to check or treat.

Name (optional, only appears on your printout)AgeFirst day of last periodMy cycle lately

Symptoms — tap each one you have, then choose how bad it is below

My periods are…

Since when?Medications & supplementsRelevant historyWhat I most want from this visit

Questions to ask

Could my symptoms be perimenopause?Is hormone therapy (HRT) an option for me? What are the risks and benefits?Are there non-hormonal options I could try?Which blood tests or checks make sense for me (thyroid, iron, vitamin D, bone density)?What can I change in sleep, food and movement to help?Who else should be on my care team?When should we follow up, and what should I track until then?

My perimenopause visit

11/11/2026

Cycle

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Symptoms

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Medications & supplements

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Relevant history

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What I want from this visit

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My questions

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Notes

Made with the Perimenopause Directory · perimenopausedirectory.com · Every listed provider holds the Perry Academy Perimenopause Certificate®

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