PRINTABLE
Menopause Health Report: one page for your OB visit
Editorially reviewed on October 29, 2026Medical review: pending
Quick answer
The Health Report is a one-page summary you fill in before a consult: your top symptoms and how long you have had them, how your periods have changed, your health history, what you take, and what you want to discuss. Hand it to your doctor at the start. It saves time and keeps the conversation on what matters to you.
Why one page beats a long story
Most OB consults in the Philippines are short. A single page your doctor can scan in a minute gets your key facts across before the clock runs out. It also covers the history a doctor needs before discussing HRT, such as clots, breast cancer, liver disease or unexplained bleeding, so the discussion can move forward instead of stopping at "let's see next time".
If you used our symptom diary, it can fill much of this in for you, on your device. Or copy the numbers from the printable diary.
Tips for filling it in
- Be specific: "woke 3 times a night, 5 nights a week" beats "hirap matulog".
- Say how it affects your life: work, driving, patience with the kids, relationships.
- List everything you take, including vitamins, herbal products and teas. Some interact with medicines.
- Write down what you want. "I'd like to discuss HRT" or "I'd like to know my options without hormones" are both fine things to ask.
- Bring a copy for yourself to take notes on.
Need help with the words? Use our questions for your OB and the "It's just stress" script.
Printable: My menopause Health Report
Name (optional): ____________ Age: ____ Date: ____________
1. My main reason for this visit
2. My top three symptoms
| Symptom | Since when | How often | How bad (0 to 3) | How it affects my life |
|---|---|---|---|---|
3. My periods
- First day of my last period: ____________
- Cycles are now: same / shorter / longer / skipping / stopped
- Flow: lighter / same / heavier / flooding
- Bleeding between periods or after sex: yes / no
- Any bleeding after 12 months with no period: yes / no (if yes, tell your doctor first)
4. My health history (circle any) Blood clot in leg or lung / stroke / heart attack / breast cancer / other cancer / liver disease / migraine with aura / high blood pressure / diabetes / thyroid problem / PCOS / osteoporosis or fracture / hysterectomy / ovaries removed / smoker
Family history (mother, sisters): breast cancer / ovarian cancer / hip fracture / heart disease at a young age
5. What I take now (medicines, vitamins, supplements, herbal)
6. What I have already tried and how it went
7. What I want to discuss today (tick)
- Whether this is perimenopause or menopause
- Hormone therapy (HRT), benefits and risks for me
- Options without hormones
- Vaginal dryness or pain with sex
- Sleep, mood or brain fog
- Tests I may need (thyroid, bone density, mammogram)
- Contraception, if I can still get pregnant
8. Notes from my doctor
Made by the patient using a free educational template. Not a diagnosis.
Frequently asked questions
What should I bring to my first menopause consult?
This Health Report, a few weeks of symptom diary if you have it, a list of your medicines and supplements, and any recent lab or imaging results.
Why does my doctor ask about clots and breast cancer?
Those affect which treatments are safe for you. Having the answers ready keeps the consult moving.
Can I bring this to a teleconsult?
Yes. Send it as a photo or file at the start, or read from it. See find a doctor for teleconsult options.
Is my information sent anywhere?
No. This is a paper template. If you use our online diary, the report is built on your device. See privacy by design.
Keep reading
Sources
This guide is for information. Talk to a doctor before starting, stopping or changing any treatment.