Consultation note - detailed

EXPLANATORY NOTES
[+] yes, present, positive
[-] no, absent, negative
[~] equivocal
[\] not performed, not applicable
[?] unknown, unsure
{ } annotation, comment

ENCOUNTER
Type:
[-] consultation face-to-face
[-] consultation by video
[-] consultation by telephone
[-] non-consultation (file note)

Special arrangements:
[-] interpreter
  language: 
  details: 
  
[-] chaperone
  details:

PRESENTING COMPLAINTS OR ISSUES
Reasons for visit:
[-] new problem/issue
[-] review/follow-up

Presenting symptoms:
[+] 
[-]

History of presenting complaint:
  Onset: 
  Location: 
  Severity (/10): 
  Quality: 
  Timing: 
  Context: 
  Aggravated by: 
  Relieved by:

Associated symptoms:
[+] 
[-]

Treatment to date:
-

Relevant diagnostic investigation results: 
[+] 
[~] 
[-] 
[?]

History since last contact:
-

Patient's or carer's ideas, concerns and expectations:
-

PAST MEDICAL HISTORY
Relevant past medical history:
[+] 
[-]

Detailed list:
1: ?
  Date of onset/Diagnosis/es: 
  Management: 
  Current status:

2: ?
  Date of onset/Diagnosis/es: 
  Management: 
  Current status:

3: ?
  Date of onset/Diagnosis/es: 
  Management: 
  Current status:

4: ?
  Date of onset/Diagnosis/es: 
  Management: 
  Current status:

5: ?
  Date of onset/Diagnosis/es: 
  Management: 
  Current status:

MEDICATIONS
Current medications:
  Name: 
  Form: 
  Route: 
  Dose: 
  Frequency: 
  Duration: 
  Reason: 
  
  Name: 
  Form: 
  Route: 
  Dose: 
  Frequency: 
  Duration: 
  Reason:

Past medications:
  Name: 
  Started: 
  Ceased: 
  Reason: 
  Reason ceased:

Name: 
  Started: 
  Ceased: 
  Reason: 
  Reason ceased:

ALLERGIES AND ADVERSE REACTIONS
[-] Causative agent: 
  Reaction: 
  Date first experienced: 
  
[-] Causative agent: 
  Reaction: 
  Date first experienced: 
  
[-] Causative agent: 
  Reaction: 
  Date first experienced:

FAMILY HISTORY
Relevant family history:
[+] 
[?] 
[-]

Family genetic screening:
[+] 
[?] 
[-]

SOCIAL HISTORY
Accommodation:
[-] lives alone
[-] lives with partner
[-] lives with family
[-] lives in share accommodation
[-] lives in hostel
[-] no permanent home

Smoking:
[-] never smoked
[-] current smoker
[-] ex-smoker
  If smoker, pack-year history:

Alcohol intake:
[-] nil
[-] alcohol use
  If yes, standard drinks per week:

Exercise:
[-] regular exercise
  If yes:
  Type: 
  Frequency:

Diet:
[-] omnivorous
[-] vegetarian
[-] vegan
[-] pescatarian
[-] gluten-free
[-] lactose-free
[-] low FODMAP

Occupational history:
  Current employment: 
  Occupation: 
  Employer: 
  Date started:

Previous employment (if relevant): 
  Occupation: 
  Years: 
  Occupation: 
  Years:

Educational history:
  Highest level of education: 
  Discipline/s:

Social contact: (hours per week)
  Online social interaction (telephone/video calls): 
  Screen time: 
  Social media use: 
  Sport/physical/recreational activities:

Services and care received:
-

SAFETY AND RISKS
Risks to self:
-

Risks to others:
-

Relevant clinical risk factors:
  Risk: 
  Assessment scale: 
  Outcome: 
  Risk mitigation: 
  
  Risk: 
  Assessment scale: 
  Outcome: 
  Risk mitigation:

Risk: 
  Assessment scale: 
  Outcome: 
  Risk mitigation:

IMMUNISATIONS
Previous immunisations:
  Vaccine: 
  Date/s given: 
  Details:

Vaccine: 
  Date/s given: 
  Details:

SYSTEMS REVIEW

PHYSICAL EXAMINATION
Relevant examination findings:
[+] 
[~] 
[-]

ASSESSMENT
Clinical summary:
[+] 
[~] 
[-]

Problems and issues:
-

Diagnosis/es:
1. 
2.

Differential diagnosis:
-

MANAGEMENT PLAN
Procedures performed:
-

Diagnostic investigations requested:
-

Referrals:
-

Patient information and advice:
-

Medication:
-

Medical devices:
-

FOLLOW-UP
Outstanding issues:
-

Next appointment:
-

Consultation note - detailed

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