RRM Fertility Consult Template

HPC: [description of the history of the presenting complaint] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) GP: [number of previous pregnancies (G) and births (P)] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) TTC: (trying to conceive length of time) [duration of time the patient has been trying to conceive] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Previous fertility treatments: [details of any previous fertility treatments received, including type and outcome] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Medications: [list of all current medications, including dosage, frequency, and reason for use] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bulleted list.) Allergies: [list of known allergies, including type of allergen and reaction] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bulleted list.) Phx: [description of past medical history and relevant health conditions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Menstrual Hx: Menarche [age at menarche] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Period length [typical duration of menstrual bleeding] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Period pattern (include days and heaviness of each day as H for heavy, M for medium, L for light, VL for very light, and B for brown bleeding) [detailed description of menstrual bleeding pattern, including days and heaviness levels for each day] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a descriptive sentence.) total cycle length [average total length of menstrual cycle] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) any fertile mucus (clear stretchy or wet sensation, include which day of the cycle) [description of fertile mucus presence, including sensation and day of cycle observed] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a descriptive sentence.) luteal phase length [length of the luteal phase of the menstrual cycle] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) bleeding in the cycle other than menstruation [description of any bleeding occurring outside of regular menstruation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a descriptive sentence.) Endometriosis screen: Pain with periods (severity rating score out of 10), which days [description of pain experienced during periods, including severity score out of 10 and specific days of the cycle] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) Pain on intercourse (deep or vaginal) [description of pain experienced during intercourse, specifying if deep or vaginal] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) Pain in other times of cycle (time of cycle and severity) [description of pain experienced at other times in the cycle, including specific timing and severity] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) Bladder pain or symptoms with period [description of any bladder pain or symptoms experienced during periods] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) bowel pain with menstruation or other times [description of any bowel pain experienced with menstruation or at other times] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) analgesia needed - what taken and how often [details of analgesia required, including type taken and frequency of use] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) PMS: (include symptoms, number of days, and resolution with menses) [description of premenstrual syndrome symptoms, including type of symptoms, number of days experienced, and how they resolve with menses] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) PCOS screen: Hirsutism: sites, description [description of hirsutism, including affected sites and characteristics] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) Acne: age, severity, treatment needed, triggers [description of acne, including age of onset, severity, treatments used, and identified triggers] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) Prolactin screen: Ni allergy- (cheap jewelry rash) [presence of nickel allergy, specifically cheap jewelry rash] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) Dermagraphism [presence of dermagraphism] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) skin issues/ rashes/ warts [description of any other skin issues, rashes, or warts] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) thrush [history or presence of thrush] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) galactorrhoea [presence of galactorrhoea] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) Insulin Resistance Screen: Weight history: [detailed weight history, including significant changes or patterns] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) central distribution [description of fat distribution, specifically if central] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) skin tags [presence and location of skin tags] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) Social: Diet: including carbohydrate intake [description of dietary habits, specifically including carbohydrate intake] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Lifestyle: exercise [details of exercise routine, including type, frequency, and duration] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) alcohol [details of alcohol consumption, including frequency and amount] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) smoking [smoking status, including type, frequency, and duration if applicable] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) CST: [date and results of most recent Cervical Screening Test] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) Mamograms: [dates and results of most recent mammograms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) Fhx: Diabetes: [family history of diabetes, including affected relatives] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) PCOS: [family history of PCOS, including affected relatives] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) Endometriosis: [family history of endometriosis, including affected relatives] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) Thyroid problems: [family history of thyroid problems, including affected relatives] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) Autoimmune: [family history of autoimmune conditions, including affected relatives] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) Other: [any other significant family medical history not listed above] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a descriptive sentence.) Partner- SFA seminal fluid analysis done before/ results: [details of partner's seminal fluid analysis, including whether it was done previously and the results] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Investigations done to date: [summary of all investigations performed to date, including type, date, and key findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bulleted list.) A: [assessment of the patient's condition based on all gathered information] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Plan: antenatal screen [details of antenatal screen plan] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bulleted list item.) hormone profile [details of hormone profile plan] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bulleted list item.) infectious cervix screen [details of infectious cervix screen plan] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bulleted list item.) ultrasound [details of ultrasound plan] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bulleted list item.) charting [details of charting plan] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bulleted list item.) referrals. [details of referral plan] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bulleted list item.)