Vestibular Initial

Section: Patient Information [Name, Date of Birth, Address, Contact Information] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in list format.) [Employment status, physical demands of job, and work-related activities] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) [General exercise and activity levels] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) Section: Medical History [List existing and past medical conditions] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) [Details of previous vestibular or neurological treatments/surgeries] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) [Mention any allergies] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) [Mention current medications including vestibular suppressants, antidepressants, antihypertensives, etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) [Mention family medical history of conditions that may impact vestibular function] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) Section: Social History [Mention relevant social history like home setup, history of falls, alcohol or tobacco use, or lifestyle factors that may affect balance] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) Section: Current Condition/Complaint [Detailed description of dizziness, vertigo, imbalance, nausea, falls, etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) [Date of onset or specific triggering event] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) [Description of how symptoms began] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) [Details of prior vestibular therapy, ENT/neuro assessments, or other relevant interventions] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) [Describe symptom pattern, frequency, duration, aggravating/easing factors] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) Section: Patient Goals [Short-term physiotherapy goals and time frame] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in bullet point format.) [Long-term physiotherapy goals and time frame] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in bullet point format.) Section: Objective [Vestibular assessment findings including oculomotor exam, positional tests, balance and gait testing, motion sensitivity, symptom reproduction] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in bullet point format.) [Include any rating scales used, e.g., DHI, ABC scale] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.) Section: Treatment Subsection: Education [Education provided about vestibular system, cause of symptoms, role of rehab] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) Subsection: Hands-on treatment [Manual techniques such as canalith repositioning maneuvers or instructions for home-based maneuvers] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in bullet point format.) Subsection: Active therapy / exercises provided in-session [List of vestibular exercises administered, including dosage/frequency if relevant] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in bullet point format.) Section: Assessment [Clinical impression] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) [Prioritized problems] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in bullet point format.) [Progress toward goals] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) [Barriers] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) Section: Plan [Ongoing vestibular rehab focus areas such as habituation, adaptation, balance retraining] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) [Recommended frequency and duration of therapy] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) [Home exercise program details including dosage/frequency] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in bullet point format.) [Safety strategies at home if applicable] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) [Consider referral if red flags or poor response to treatment] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph format.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include 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 the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)