MD Initial Assessment

SubjectivePresenting Complaint - [Detailed description of primary injury, problem, complaint, or symptom.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Date of onset and/or date of surgery.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Description of how the injury occurred or complaint began.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Details of any prior therapy, interventions, and/or surgery.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Describe progression of complaint and nature of symptoms.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Symptoms - [How long the symptoms last, resting, during exercise, post exercise.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [How symptoms affect movement and function.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Red flags: angina, incontinence, dizziness, loss of memory, nausea, fainting, lightheadedness.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Pain - [Location on the body, is it localised or referring.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Intensity, is it sharp, dull, achy, tingly, hot.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Any pain mentioned, location, intensity, type and duration. Rating out of 10, 10 being most.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Aggravators.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Relievers.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Medical History - [Any injuries current, previous or ongoing.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Any surgeries or previous medical interventions.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Safe to exercise clearance.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [List of chronic health conditions (e.g., diabetes, cardiovascular disease, arthritis, etc.).] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Careteam - [Specialist appointments, most recent appointment and upcoming reviews.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Other allied health professionals involved.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Social History - [Occupation, work from home or in office.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Activities of daily living and how the individual's pain/condition affects these.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Restrictions in mobility, recreational tasks or work.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Accessibility to clinic: drives, transports, walks, availability for attendance.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Lifestyle - [Alcohol intake.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Smoker or not.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Hydration.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Sleep.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Basic dietary habits or nutritional concerns.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Exercise History - [Previous exercise history, use of resistance training equipment or gym spaces.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Current exercise history.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [List of currently available home exercise equipment.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Use of fitness trackers, wearables, or exercise apps.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Adherence to previous exercise program: full, partial, poor.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Psychological Readiness / Mental Health - [Confidence in returning to exercise or physical activity.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Current mental health status: anxiety, depression, stress levels.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Family, peer, or community support related to exercise or rehabilitation.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Barriers - [Main preventers from currently completing regular exercise.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Possible future barriers to exercise adherence.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Goals - [Short-term goals and time frame for achieving these goals.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Long-term goals and time frame for achieving these goals.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Medication - [Any current medication.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Any previous medication.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Necessary medication for exercise, GTN spray, asthma puffer.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) --- ObjectiveObservation - [Posture, muscle tone, swelling, asymmetry, gait pattern.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Assistive devices, orthotics, strapping, or supports.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [General presentation: pain behaviors, facial expressions, fatigue.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Vital Signs - [Resting heart rate (HR).] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Resting blood pressure (BP).] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Oxygen saturation (SpO2).] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Blood glucose levels.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Anthropometrics - [Height.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Weight.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [BMI.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Waist circumference.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Range of Motion (ROM) - [Active and passive ROM of relevant joints.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Joint stiffness, end feel, or compensatory movement patterns.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Strength Testing - [Manual Muscle Testing (MMT) results with grading.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Functional strength tests (e.g., sit-to-stand, heel raises, push-ups).] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Reported weakness or fatigue during testing.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Functional Capacity Tests - [6-Minute Walk Test (6MWT).] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Timed Up and Go (TUG).] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Sit-to-Stand Test (30s or 5-rep).] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Stair climb test.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Balance assessments (single leg stance, tandem walk).] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Aerobic Capacity/Cardiovascular Fitness - [VO2 max estimation via submaximal or graded tests.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Heart rate response to exercise.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Rate of Perceived Exertion (RPE) at specific workloads.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Blood pressure and SpO2 response to exercise.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Recovery heart rate.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Mobility / Gait - [Observations of walking pattern, stride length, use of aids, or abnormalities.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Gait speed tests (e.g., 10m walk test).] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Balance / Proprioception - [Static and dynamic balance testing.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Falls risk screening results.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Neuromuscular Control / Coordination - [Observations of motor control during functional or loaded tasks.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Upper/lower limb coordination (e.g., heel-to-shin, finger-to-nose).] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Flexibility / Muscle Length - [Hamstring, hip flexor, quadriceps, calf, shoulder ROM/muscle length.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Tightness or restriction noted.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Special Tests - [Orthopaedic or neurological tests relevant to condition (e.g., straight leg raise, Hawkins-Kennedy, etc.).] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Exercise Tolerance - [Type, intensity, and duration of activity completed during initial session.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [RPE reported during or after activity.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Heart rate, blood pressure, or symptoms during activity.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Reasons for test termination if not completed.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) --- Assessment - [Summary of primary presenting problem in context of functional limitations.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Client’s current physical capacity and exercise tolerance including observed strengths, limitations, and functional deficits.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Impact of comorbidities or chronic health conditions on movement, exercise safety, or recovery.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Psychosocial or behavioural factors influencing exercise engagement, confidence, or adherence.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Identified physical or psychological barriers to safe or consistent exercise participation.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Clinical impression of exercise risk stratification (low, moderate, or high risk based on current status).] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Client’s observed response to exercise testing or physical activity during the session.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Exercise readiness status: safe to begin, requires modifications, or needs further clearance before starting.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) --- LTYB Program - [Number of programs provided (e.g., full session vs. partial session).] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Type of program issued: 9-exercise full session or 3-exercise first round only.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Frequency of completion (e.g., 2x/week, every second day).] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Any specific warm-up prescribed prior to the LTYB program.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) --- Plan - [Recommendations regarding follow-up or review (e.g., supervised session, phone check-in, next appointment date).] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Summary of exercise plan to be commenced or continued, including key focus areas (e.g., strength, mobility, balance, aerobic fitness).] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Structure of the exercise plan (e.g., gym-based, home-based, circuit, 1:1 supervision).] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Frequency, intensity, time, and type (FITT) guidelines provided.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Monitoring strategies advised (e.g., RPE, heart rate, glucose levels, pain tracking).] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Education provided regarding exercise safety, injury prevention, pacing, or symptom monitoring.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Referrals to other health professionals or services.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Adjustments planned based on client’s presentation or expected progression.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit section entirely. Never come up with your own patient details, diagnosis, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes or clinical note as reference. )