Menopause/Perimenopause GP MBS

Perimenopause and Menopause Health Assessment Date: [date of assessment] Patient Details: Name: [patient's full name] Date of Birth: [patient's date of birth] Age: [patient's age] Address: [patient's residential address] Contact Number: [patient's contact telephone number] Reason for Assessment: [describe the primary reason for the patient seeking this perimenopause and menopause health assessment, including presenting symptoms, concerns, or health goals] Medical History: Past Medical History: [document all relevant past medical conditions, diagnoses, and significant health events] Surgical History: [list all previous surgical procedures and the dates performed] Medications: [detail all current medications, including prescription, over-the-counter, supplements, and herbal remedies, along with dosages and frequencies] Allergies: [list all known allergies to medications, foods, or environmental factors, and the nature of the reaction] Family History: [document relevant family medical history, particularly concerning cardiovascular disease, cancer, osteoporosis, and other chronic conditions pertinent to menopause] Social History: [describe relevant social factors including smoking status, alcohol consumption, recreational drug use, occupation, living situation, and support systems] Menstrual History and Menopausal Symptoms: Menstrual Cycle Details: [describe menstrual cycle regularity, duration, flow, last menstrual period, and any changes observed] Menopausal Stage Assessment: [assess and document the patient's current menopausal stage based on symptoms and menstrual history, e.g., perimenopause, menopause, postmenopause] Symptom Checklist: - Vasomotor Symptoms: [document presence and severity of hot flushes, night sweats] - Psychological Symptoms: [document presence and severity of mood changes, anxiety, depression, irritability, brain fog, memory issues] - Sleep Disturbances: [document presence and severity of insomnia, restless sleep, difficulty falling or staying asleep] - Genitourinary Symptoms: [document presence and severity of vaginal dryness, dyspareunia, urinary urgency, frequency, recurrent UTIs] - Musculoskeletal Symptoms: [document presence and severity of joint pain, muscle aches, changes in bone density] - Sexual Health: [document presence and severity of changes in libido, sexual function, or discomfort] - Other Symptoms: [document any other relevant symptoms reported by the patient] Physical Examination: General Appearance: [describe general appearance, body habitus, and signs of distress] Blood Pressure: [document blood pressure reading] Heart Rate: [document heart rate reading] Weight and BMI: [document patient's weight and calculated Body Mass Index] Clinical Examination Findings: [document relevant physical examination findings related to cardiovascular, respiratory, abdominal, breast, and pelvic systems as clinically indicated] Investigations: Pathology Results: [document results of any blood tests, including hormone levels (FSH, LH, Oestradiol), thyroid function, lipid profile, liver and kidney function, glucose] Imaging Results: [document results of any relevant imaging, such as bone density scans (DEXA) or pelvic ultrasounds] Other Investigations: [document results of any other relevant diagnostic tests or screenings] Assessment and Diagnosis: [summarise the patient's current health status, menopausal stage, and any diagnoses made based on history, symptoms, physical examination, and investigations] [describe the differential diagnoses considered] Management Plan: Algorithm Applied: [state which specific algorithm(s) from "A Practitioner’s Toolkit for Managing Menopause" were utilised in developing the management plan] Lifestyle Modifications: - Dietary Advice: [provide specific dietary recommendations relevant to menopause and overall health] - Exercise Recommendations: [provide specific exercise guidelines and physical activity suggestions] - Stress Management: [suggest strategies for stress reduction and mental well-being] - Sleep Hygiene: [provide advice on improving sleep patterns] Hormone Replacement Therapy (HRT) Discussion: - Benefits and Risks: [document detailed discussion of the benefits and risks of HRT, tailored to the patient's individual profile] - Prescribed HRT Regimen: [detail the specific HRT type, dosage, route, and frequency if initiated or modified] - Patient Decision and Consent: [document patient's informed decision regarding HRT and verbal or written consent] Non-Hormonal Therapies: [detail any non-hormonal pharmaceutical or complementary therapies recommended for symptom management] Referrals: [document any referrals to other specialists or allied health professionals, e.g., gynaecologist, dietitian, psychologist, physiotherapist] Screening and Prevention: [outline recommendations for ongoing health screenings, e.g., mammograms, cervical screening, bone density monitoring] Follow-up Plan: [specify the date and purpose of the next scheduled review] Patient Education: [summarise key educational points provided to the patient regarding menopause, symptoms, and management options] MBS Item Numbers Considered/Applied: [list relevant Medicare Benefits Schedule (MBS) item numbers applicable to this consultation and assessment] (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)