Menopause Intake Form - Nova Endometriosis, Pelvic Pain & Menopause Clinic

Patient Criteria

This service is available to women experiencing perimenopausal or menopausal symptoms.

A dedicated care pathway has been developed specifically for this program.

Please note that any appointments requested outside of the program pathway will incur private practice fees.

Fees

After submitting the form, you will receive a link to book your first appointment with our clinic nurse. An out-of-pocket fee of $100 is required to schedule this appointment.

The menopause program fee covers your initial nurse appointment and nurse follow-up appointment as well access to group sessions including Menopause Matters Education Class, Endo Core Exercise Class, Menopause Nutrition, Menopause Mindset, and Art Therapy. Please note there is a $215 fee for the initial GP consultation which will have a Medicare rebate attached.

Late-cancellation (within 24 hours of your appointment) and non-attendance will result in withdrawal from the program.

I have read the information above and understand that a registration fee is required to book with the clinic. *

Data Collection and Privacy Statement

The Endometriosis and Pelvic Pain Clinic is supported by temporary funding from the Commonwealth Government. As part of this funding we are required to collect de-identified data about service provision and patient demographics and outcomes. It is hoped that via this data we can assess service effectiveness and lobby for ongoing funding to support continuation of the clinic.

As a Commissioned Service Provider of Murrumbidgee Primary Health Network (MPHN) we are required to have appropriate controls to protect your personal information and use your personal information for authorised purposes only as per the Privacy and Personal Information Protection Act 1998 No 133 - NSW Legislation.

Nova Health Co will collect your information via Snapform (an online questionnaire platform), and store your information on Best Practice (Nova Health Co's clinic software). A copy of Best Practice Privacy Policy can be located here: https://bpsoftware.net/privacy-policy/ and Snapform: https://snapforms.com.au/privacy-policy/.

De-identified responses will be sent to MPHN and the Australian Government Department of Health and Aged Care for the purpose of informing and contributing towards the evaluation of the program. It will also be used for statistical, evaluation and planning purposes at an aggregated level for the needs assessment, which is a publicly available document.

You have a right to access any personal information we hold and you may ask us to update or correct your personal information. For further information on how you can access your personal information or contact us with any questions or privacy related complaints, please visit our Privacy Statement https://novahealthco.com.au/wp-content/uploads/2024/03/Practice-Information-Sheet.pdf or contact us at (02) 6921 2040.

Please also see MPHN Privacy Statement https://mphn.org.au/disclaimer-privacy-statement.

You can withdraw consent for deidentified data sharing at any time by contacting us on (02) 6921 2040 or emailing eppcadmin@novahealthco.com.au.

I consent to my data collection and sharing of my de-identified data as outlined above *

YesNo

Patient Details

First Name *

Last Name *

Date of Birth *

Contact Phone Number *

Email Address *

What was your assigned sex at birth? *

FemaleMaleIntersex

What are your pronouns? *

She/herHe/himThey/themOther

Are you of Aboriginal and/or Torres Strait Islander origin? *

Do you identify as part of the LGBTQI+ community? *

YesNoPrefer not to say

Do you identify as a person with a disability? *

YesNoPrefer not to say

Do you identify as coming from a culturally and linguistically diverse background? *

YesNoPrefer not to say

What is your main concern? *

Do you have a regular GP? If so, please list their details below. *

Are you currently employed? If so what is your job/role? *

Are you already on treatment for menopause? If so, what? *

Greene Climacteric Scale

The Greene Scale provides a brief measure of menopause symptoms. It can be used to assess changes in different symptoms, before and after menopause treatment. Three main areas are measured:

Psychological (items 1-11)
Physical (items 12-18)
Vasomotor (items 19, 20)

Score: *

Is there anything else you would like to add?

Thank you for completing this questionnaire.

If you have any concerns/questions please email eppcadmin@novahealthco.com.au.

UPON SUBMITTING THIS QUESTIONNAIRE YOU WILL RECEIVE AN EMAIL AT THE ADDRESS PROVIDED CONTAINING A LINK TO BOOK AN APPOINTMENT. PLEASE CHECK YOUR JUNK OR SPAM FOLDER IF YOU DO NOT SEE THE EMAIL IN YOUR INBOX.

PLEASE NOTE THAT YOU WILL NOT BE CONTACTED DIRECTLY TO BOOK AN APPOINTMENT. IF YOU EXPERIENCE ANY ISSUES PLEASE CONTACT THE CLINIC ON (02) 6921 2040.