Initial Medical Assessment

HISTORY: [document the patient's chief complaint, including onset, aggravating factors, relieving factors, location of pain, radiation, and associated symptoms such as pins and needles, numbness, weakness, or instability] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) WORK: [describe the patient's current work status, including work days per week and any physical activities performed during work breaks] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) PAST HISTORY: [detail any relevant past medical history, particularly concerning the chief complaint or other significant conditions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) PAST SURGERY: [list any past surgical procedures] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) FAMILY HISTORY: [document any relevant family medical history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) GENERAL HEALTH: [describe the patient's overall general health status] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) HOBBIES: [describe the patient's hobbies and how they relate to or are affected by their current condition, including any new activities started] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) SOCIAL: [document the patient's social situation, including household members] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) TREATMENTS: [list past and current treatments for the chief complaint, including medications, injections, and therapies, and their effectiveness] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) MEDS: [detail current medications, including over-the-counter and as-needed medications, and their perceived effectiveness] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) INVESTIGATIONS: [summarize results of relevant diagnostic investigations, including imaging findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) EXAM: [document relevant physical examination findings, including patient general appearance, range of motion, special tests, and palpation findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) ASSESS: [provide a clinical assessment or diagnosis based on the history and examination findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) GOALS: [document the patient's stated goals for treatment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) PLAN: [outline the proposed management plan, including referrals to other healthcare professionals, follow-up appointments, and specific recommendations for exercises or activity modifications] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) (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 included 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.)