HSMC.Menopause Health Assessment

Streamlined Menopause Health Assessment Template Demographics [Document any relevant social history including relationship status, number and age of children, occupation and working status, smoking status, alcohol consumption.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in paragraph format.) Family History [Document any relevant family history including family history of breast, ovarian or uterine cancer, or premature menopause. Include age of menopause in mother, grandmother or sisters if known.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in paragraph format.) Menopausal Status & Symptoms LMP (Last Menstrual Period): [Insert date or approximate timing of last normal menstrual period.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Periods: [Describe pattern of current menstruation, including regularity, length of cycle, heaviness, pain, and any management strategies being used.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Current Menopausal Status: [Pre-menopausal (symptomatic) / Peri-menopausal / Post-menopausal] (Only include if explicitly mentioned or clearly inferable from transcript, contextual note or clinical note. Confirm with patient. Do not include if status is not confirmed.) Modified Greene Climacteric Scale Score: [Enter numeric score if patient completed scale.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Most Impactful Symptoms (Patient Identified Top 2–3): [Document up to three most bothersome menopausal symptoms as identified by the patient.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in list format with brief description.) Hot Flushes/Night Sweats: [Describe severity and impact.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Mood Changes (Anxiety/Irritability/Low Mood): [Describe impact and symptoms.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Sleep Disturbances: [Describe nature and effect.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Vaginal Dryness/Dyspareunia: [Describe if reported.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Brain Fog/Memory: [Describe cognitive symptoms.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Joint Pains: [Describe location or severity.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Palpitations: [Describe frequency or context.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Reduced sexual desire: [Document only if discussed.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Itchy skin: [Describe symptoms.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Tiredness: [Include description.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Urinary problems: [Include only if discussed.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Irregular Periods: [Document pattern.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Weight Gain: [Include description.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Headaches: [Include details.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Other: [Free text description of any other symptoms mentioned.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Overall Impact on QoL [Summarise how menopausal symptoms are impacting quality of life, including emotional, physical, social or occupational aspects.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as paragraph.) Brief Medical History & Contraindications History of Breast Cancer? [Y/N/U] Undiagnosed Vaginal Bleeding? [Y/N/U] History of DVT/PE/Stroke/Heart Attack? [Y/N/U] Active Liver Disease? [Y/N/U] (Only include answers if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Physical Examination Blood Pressure: [Insert if measured] Height: [Insert in cm] Weight: [Insert in kg] BMI: [Auto-calculate] General Observation: [Brief comment e.g., “NAD,” “Well-appearing”] (Only include if values are explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Investigations & Referrals Cervical Screening Test (CST): [Due / Not Due / Date of Last: DD/MM/YYYY] (Only include if explicitly mentioned.) Mammogram: [Due / Not Due / Date of Last: DD/MM/YYYY] (Only include if explicitly mentioned.) Bone Densitometry (DEXA): [Due / Not Due / Date of Last: DD/MM/YYYY / Not Indicated] (Only include if explicitly mentioned.) Other Investigations: [List investigations such as TSH, glucose, lipids, FSH etc.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Referrals: [List any referrals made during consult such as gynaecology, psychology, dietetics etc., and include reason for referral.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.) Management Plan & Preventative Health Advice Non-Pharmacological Strategies Agreed: [Provide lifestyle advice regarding nutrition, physical activity, stress management, and sleep hygiene. Include smoking cessation, alcohol moderation, and weight management where relevant. Include any specific advice discussed during the consult.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in paragraph format.) Pharmacological Strategies Agreed: [Summarise discussions around hormonal and non-hormonal therapy. Mention key benefits such as relief from hot flushes, mood, sleep, vaginal dryness, bone health. Mention key risks such as breast cancer risk with combined HRT, and clotting risk with oral formulations.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in paragraph format.) Patient Preference: [State the patient’s preferred treatment plan or decision following the consult.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in sentence format.) Management Plan Summary [Summarise the agreed plan including lifestyle changes, medications or therapies, follow-up investigations and timing for review or next steps.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in paragraph format.) (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.)