Functional Doctor Template

CONSULTATION: HISTORY: [State reason for visit. Give a detailed account of the complaint. Mention presenting complaint and detailed history of presenting complaint. When complaint started. Is it acute or chronic. What is the significance of the complaint and any other comments about the complaint, in bullet points] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Mention reasons for visit, chief complaints such as requests, symptoms etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Mention duration/timing/location/quality/severity/context of complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Mention List anything that worsens or alleviates the symptoms, including self-treatment attempts and their effectiveness] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Progression: Describe how the symptoms have changed or evolved over time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Previous episodes: Mention detail any past occurrences of similar symptoms, including when they occurred, how they were managed, and the outcomes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Mention Impact on daily activities: explain how the symptoms affect the patient's daily life, work, and activities.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Associated symptoms: Mention any other symptoms (focal and systemic) that accompany the reasons for visit & chief complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Timeline of issues including onset and the patient’s age or the year of onset] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Symptom Review: Assimilation: [Assimilation-related symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Defense and Repair: [Defense and repair-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.) Biotransformation: [Biotransformation and detoxification-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.) 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.) 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.) Past Medical History: (Write past medical history as a time line chronologically.) - [Mention Contributing factors including past medical and surgical history, investigations, treatments, relevant to the reasons for visit and chief complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Mention Social history that may be relevant to the reasons for visit and chief complaints.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Mention Family history that may be relevant to the reasons for visit and chief complaints.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Mention Exposure history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Mention Immunization history & status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Other: Mention Any other relevant subjective information] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Lifestyle factors: [Describe relevant lifestyle factors. Include factors about Nutrition, Sleep, movement or exercise, Mindset, stresses and community] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Review of Supplements and Medications: [List current medications with dosage and start date and end dates] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [List current supplements with dosage and start date and end dates] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Examination: [Provide examination findings in a detailed way. Try to arrange by body systems. Please give values if stated such as blood pressure, respiratory rate] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Review of Test Results: [List previous test results with test name and outcome. Use values. If units are not given the state "NO UNITS GIVEN"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Antecedents : Predisposing factors: [Inherited factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 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.) Mediators / Perpetuators [Current mediators/perpetuating factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Assessment: - [The clinician’s likely diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Do not invent or infer a diagnosis.) - [Clinician’s differential diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Do not invent or infer a diagnosis.) - [Root causes described in the consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Overall Plan [Provide a brief summary of the overall treatment plan and recommendations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Nutrition: [List plans and all recommendations relating to food and nutrition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Rest and Renew: [List the plans or recommendations related to rest. Especially related to any breath work, vagus nerve work, mindset and meditation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Sleep: [List the future plan or any recommendations for sleep, sleep patterns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Movement: [List plans for recommendations for movement, exercise] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Supplements: [List new supplements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [List changes to current supplements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [List doses and frequency. Mention if tablets or powder] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Mention products by name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Medications: [List by each medication. For each medication, list by brand name, generic name, dosage with units, quantity and any additional comments for each medication if provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Products / tests: [List tests ordered. Important to add when to order and cost. Any other comments for each test] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Provide reason for tests] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Investigations planned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Next Steps: [List follow-up appointments and any next steps or subsequent plans] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Relevant other actions such as counselling, referrals etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Notes: [Include additional observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)