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View full libraryA menopause wellbeing checklist form helps employees identify workplace factors that may affect their wellbeing during perimenopause, menopause or post-menopause. It provides a structured way to discuss support needs, workplace adjustments and practical actions with a manager or HR.
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If you are supporting employee wellbeing, the toolkit brings together practical HR templates covering wellbeing needs, assessment, support, communication and review.
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Purpose
This checklist helps identify workplace factors that may affect an employee's wellbeing during perimenopause, menopause or post-menopause. It provides a starting point for discussing practical support, workplace adjustments and agreed actions.
Complete the sections relevant to your circumstances. You do not need to provide a detailed medical history or disclose information that is not necessary to discuss workplace support.
Section 1: Employee and discussion details
| Employee name | |
| Job title / department | |
| Manager / HR representative | |
| Date completed | |
| Preferred way to complete | [ ] Independently [ ] With manager [ ] With HR |
| Purpose of discussion | [ ] Initial discussion [ ] Review [ ] Follow-up to a concern |
Section 2: Wellbeing and workplace checklist
Tick any areas that are relevant to you. You may leave an item blank if it does not apply or you do not wish to discuss it.
A. Working environment and physical comfort
| Select | Consideration | Comments / support that may help |
| [ ] | Workplace temperature or hot flushes affect my comfort. | |
| [ ] |
You've seen 20% of how the Menopause wellbeing checklist form template is structured. Get the complete editable template instantly and customise it for your organisation.
Menopause symptoms can affect people differently and may change over time. Workplace factors such as high temperatures, inadequate ventilation, limited toilet access, fatigue, disrupted sleep or difficulty concentrating can make it harder for some employees to work comfortably and effectively.
A menopause wellbeing checklist form gives employees and managers a practical starting point for discussing these issues. It focuses on the employee's experience at work, the support they would find helpful and the actions that could make a difference, rather than requiring detailed medical disclosure.
The checklist prompts consideration of the working environment, physical comfort, workload, concentration, working hours and access to suitable facilities. Employees can identify relevant concerns without being expected to experience every symptom or answer every question.
Use the completed checklist to explore reasonable and proportionate measures, such as access to drinking water and toilets, improved ventilation, suitable rest breaks, temporary flexibility in working hours, changes to work allocation or adjustments to uniform requirements where practicable.
The form includes an action plan to record what has been agreed, who will take responsibility and when each action should be completed. A follow-up discussion helps establish whether the measures are effective or whether further support, an occupational health referral or a workplace risk assessment should be considered.
The checklist should be used sensitively and in line with the organisation's menopause policy, equality responsibilities and data protection arrangements. Employees should be able to discuss their needs without pressure to share personal medical details. Managers should record only information that is necessary for providing support and managing agreed actions.
Related HR resources and workflow
Explore the HR resources that may be relevant before and / or after using the Menopause wellbeing checklist form, helping you understand the wider process, maintain appropriate documentation and follow a consistent approach.
A manager's guide to supporting menopause at work provides practical guidance for UK managers on recognising workplace support needs, having sensitive conversations and responding appropriately to employees experiencing perimenopause, menopause or post-menopause.
Use these best practice actions, recommended timescales and process stages to understand when and how the Menopause wellbeing checklist form should be used, helping ensure each step is handled consistently and appropriately documented.
Understand the common mistakes to avoid when using this HR template, helping you reduce risk, prevent unnecessary costs and ensure the process is handled correctly.
It is a structured form used to identify workplace factors that may affect an employee experiencing perimenopause, menopause or post-menopause. It helps the employee and employer discuss concerns, consider support and record agreed actions. It is not a medical assessment or a statutory form.
An employee can complete it independently or with support from a manager or HR representative. The organisation should explain the purpose and confidentiality arrangements and allow the employee to raise only the concerns relevant to their circumstances. The process should be supportive rather than intrusive.
Useful topics include temperature, ventilation, access to toilets and drinking water, fatigue, sleep, concentration, workload, working hours, breaks and the availability of workplace support. The form should also record agreed actions, responsibilities and review dates without requiring unnecessary medical details.
There is no single legal duty to provide every adjustment requested because of menopause. However, employers must consider their obligations under the Equality Act 2010, including the duty to make reasonable adjustments where the legal requirements for disability apply. Employers must also meet applicable health and safety duties. ACAS guidance is available at https://www.acas.org.uk/menopause-at-work/menopause-and-the-law.
HRDocBox provides customisable HR templates designed for UK employers, helping businesses establish consistent processes and practical documentation. This checklist can be adapted to reflect your menopause policy, workplace environment, management responsibilities and internal procedures.
A dedicated HRDocBox template provides a structured starting point with relevant sections, prompts and an action-recording format that can be adapted for your organisation. AI can help tailor wording, but any generated content still needs to be checked for legal accuracy, suitability and consistency with your workplace policies. Employers remain responsible for how the form is implemented and how employee information is handled.
How this content is developed and reviewed
The Menopause wellbeing checklist form template is developed using a practical HR methodology that considers current UK employment legislation, ACAS guidance, CIPD good practice and the real-world HR process it supports. Templates and supporting information are regularly reviewed and updated, with additional reviews triggered by significant changes to legislation, guidance or established HR practice, helping ensure each document remains practical, relevant and suitable for UK employers.
Darryl Horn, Chartered HR Director
Darryl is a Chartered HR professional with over 25 years' experience in senior HR and employee relations roles.
He has extensive practical experience of managing wellbeing HR processes and founded hrdocbox to provide businesses with practical, professionally developed HR resources grounded in UK employment law and best practice.
HRDocBox has been creating practical UK HR documents since 2009.
"Darryl provides support and advice with excellent judgement, and has a strong understanding of people, policies and UK employment legislation."
"He is someone I trust; consistent, dependable, and committed to doing things properly."
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