Physiotherapy Initial Assessment

Patient information: - [employment status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [age] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [sex] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [general exercise and activity levels] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [pronouns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Consent: - [verbal consent to assessment and treatment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Acupuncture checklist: - [VCG and answers to: uncontrolled epilepsy or diabetes, recent infective skin or heart conditions, pregnancy, allergic to metals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PC: - [Presenting condition, specifying which side of the body, which limb or joint etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) HPC: - [history of presenting condition, stating exactly where the history began with this and how they got there] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [subjective information related to the presenting condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) NRS: - [pain scores] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Special Questions: - [questions about clicking, popping or grinding, sensation, giving way, power, dizziness, double vision, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 24 Hour Pattern: - [pain pattern over the day, AM / PM behaviours] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Aggs: - [list of aggravating factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Eases: - [list of easing factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PMH: - [past medical history, including threads] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) DH: - [Drug history, a list of any medications being taken] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) SH: - [any additional social history not already captured in the patient information above] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Goals / Expectations: - [patient goals and their expectations from the physiotherapist going forward through sessions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Objective: - [observations, including postural observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [list of all objective assessments divided into joints and the range of motion assessed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [power (MRC) assessed at that joint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [special tests] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) RX: - [thorough breakdown of all treatment provided in session] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [advice, education or advisories for future attention given to patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Analysis: - [diagnosis quoted in the manner of a problem list, with medical terminology] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [any differential diagnosis/contributing factors mentioned within the session] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Plan: - [plan including next appointment and any tasks agreed in session] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes or clinical note as a reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)