Initial consultation/intake

PATIENT: [Patient ID] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) [Age], DOB: [Date of Birth] (Use DD/MM/YYYY. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) [Sex, Neutering Status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Weight: [Weight] (Use kg. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Microchip #: [Microchip Number] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) VISIT: Reason: [Reason for Visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Veterinarian: [Veterinarian Name and Qualifications e.g. BVSc, MMedVet] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Check In: [Check In Date and Time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Check Out: [Check Out Date and Time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Referring Practice: [Referring Practice Name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) SUBJECTIVE: History: [Patient Name] is a [Age]-year-old [Species/Breed] presented for recheck to monitor [Condition]. The owner reports [Owner's observations and comments]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Current medications: [List of current medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) OBJECTIVE: Vitals: - Temperature: [Temperature] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Heart Rate: [Heart Rate] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Respiratory Rate: [Respiratory Rate] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Weight: [Weight] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Physical Exam: - General Appearance: [General appearance observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - EENT: [Eyes, Ears, Nose, and Throat observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Oral Cavity: [Oral cavity observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - CV: [Cardiovascular system observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Resp: [Respiratory system observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Neuro: [Neurological system observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Integument: [Integumentary system observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Abdomen/GI: [Abdominal and gastrointestinal system observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Musculoskeletal: [Musculoskeletal system observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Urogenital: [Urogenital system observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Lymph: [Lymphatic system observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) - Rectal: [Rectal exam observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Diagnostic Results: [List of diagnostic results including blood work, imaging, urinalysis, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) ASSESSMENT: [Assessment based on subjective and objective findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) PLAN: Diagnostic/Treatment Plan: [Outline the plan for ongoing treatment, medications, procedures, or further diagnostics] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Recommendations: [List of recommendations provided to the owner] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, or 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 that the information has not been explicitly mentioned in your output; simply leave the relevant placeholder or omit the placeholder completely.)