Clinic Consultation and Assessment Note

CONSULTATION: Potential Root Causes: [Root causes described in the consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely; Write in bullet point form) Antecedents: Predisposing factors: [Inherited factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely; Write in bullet point form) Acquired: [Acquired factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Triggers: [Significant triggering events and exposures] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely; Write in bullet point form) Mediators / Perpetuators [Current mediators/perpetuating factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely; Write in bullet point form) Timeline: - [Timeline of issues including onset and the patient's age or the year of onset, also include associate symptoms, triggers, mediators and antecedents for each issue; issues may include but are not limited to contributing factors including past medical and surgical history, investigations, treatments, relevant to the reasons for visit and chief complaints, social history, family history, exposure history, immunisation history and status, and any other relevant subjective information] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write past medical history as a timeline chronologically.) Matrix: Assimilation: [Assimilation-related symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Immune: [Immune, defense and repair-related symptoms or issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Structural integrity: [Structural integrity-related symptoms or issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Mental, Emotional and Spiritual: [Mental, emotional and spiritual health-related symptoms or issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Energy: [Energy-related symptoms or issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Communication: [Communication/endocrine/metabolic/neurotransmitter-related symptoms or issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Transport: [Transport/cardiovascular/lymphatic-related symptoms or issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Biotransformation: [Biotransformation and detoxification-related symptoms or issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Lifestyle factors: Sleep: [Relevant sleep factors or patterns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Move: [Relevant movement or exercise factors, as well as inability to move or exercise] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Eat: [Relevant eating, food, nutrition factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Think: [Relevant thinking, mindset, thought factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Community: [Relevant community, connections with people factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) MSQ [Full details of each separate MSQ including date completed and scores, and include everything even if scores are 0] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Review of Test Results: [Previous test results with test date, name and outcome using values; if units are not given state "NO UNITS GIVEN"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write past medical history as a timeline chronologically.)