Menopause and Perimenopause Health Assessment

**Menopause and Perimenopause Health Assessment (MBS Item 695)** History • Menopausal status: [document menopausal status including current stage, transitions, and relevant context such as surgical or treatment-related causes] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as single-line entry.) • Symptoms discussed: [list symptoms or concerns raised related to menopause and perimenopause, including physical, emotional, cognitive, or sexual health symptoms] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as comma-separated list.) • Menstrual history: [document details of menstrual patterns, timing of last menstrual period, cycle changes, or cessation; include context of surgical history if relevant] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as single-line entry.) • Medical history: [list relevant past or current medical conditions including those affecting cardiovascular, bone, or hormone-related health] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) • Family history: [list any relevant family medical history that may impact menopause management or risk assessment] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) • Contraindications to treatment considered: [list any relevant medical or personal history that could influence safety of hormone or other menopause-related treatments] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) • Psychosocial wellbeing: [summarise discussion of emotional wellbeing, stressors, supports, and mental health status in the context of menopause] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph of full sentences.) Examination • Basic physical examination performed. (Only include if explicitly mentioned in transcript or context, else omit section entirely.) • Blood pressure: [record measured blood pressure or note that it was checked] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as single-line entry.) • Height: [record measured height or note if documented] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as single-line entry.) • Weight: [record measured weight or note if documented] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as single-line entry.) • BMI: [calculate and document BMI if applicable] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as single-line entry.) Investigations and Referrals • Cervical screening (Only include if explicitly mentioned in transcript or context, else omit section entirely.) • Mammography (Only include if explicitly mentioned in transcript or context, else omit section entirely.) • Bone densitometry (DEXA) (Only include if explicitly mentioned in transcript or context, else omit section entirely.) • Additional pathology as indicated (Only include if explicitly mentioned in transcript or context, else omit section entirely. List relevant tests.) • Referrals initiated: [list referrals discussed or initiated including specialist or allied health services] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as comma-separated list.) Management • Non-pharmacological options discussed: [summarise non-medication strategies discussed including education, behavioural and lifestyle approaches] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) • Pharmacological options discussed: [summarise medical treatments discussed for symptom management] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) • Risks and benefits explored with patient (Only include if explicitly mentioned in transcript or context, else omit section entirely.) • Shared decision-making documented (Only include if explicitly mentioned in transcript or context, else omit section entirely.) • Symptom-focused management plan implemented (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Preventative Health Care Advice • Physical activity (Only include if explicitly mentioned in transcript or context, else omit section entirely.) • Smoking cessation (Only include if explicitly mentioned in transcript or context, else omit section entirely.) • Alcohol use (Only include if explicitly mentioned in transcript or context, else omit section entirely.) • Nutrition and calcium/vitamin D intake (Only include if explicitly mentioned in transcript or context, else omit section entirely.) • Weight management (Only include if explicitly mentioned in transcript or context, else omit section entirely.) • Educational resources provided as appropriate (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Team Involvement • Assistance provided under GP supervision by [document any clinical staff who contributed to the consultation, including their role and input] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as single-line entry.) • Allied health and other providers involved: (Only include if explicitly mentioned in transcript or context, else omit section entirely. List items on separate lines.) • [list any allied health clinicians or specialists involved in current care or referred to] • [list additional external services or clinics discussed or involved] • Coordination of care and communication arranged as required (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Review • Follow-up planned for [document planned timing and purpose of follow-up including ongoing symptom review, result discussion or care continuation] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as full sentence.) (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 include 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.)