Osteopath Template

Osteopath Initial Consult

A professional Osteopath template for healthcare professionals.

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Specialty

Osteopath

Used

90 times

Type

Note

Last edited

13/06/2025

Created by

John Smith

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About this template

The Osteopath Initial Consult template is designed for osteopathic practitioners to document comprehensive initial assessments of patients presenting with musculoskeletal complaints. This template includes sections for detailing the presenting complaint, complaint history, past medical history, goals, assessment findings, diagnosis, treatment, and treatment plan. It is ideal for osteopaths to capture detailed patient information, ensuring a thorough understanding of the patient's condition and facilitating effective treatment planning. This template is particularly useful for documenting initial consultations, helping osteopaths provide tailored care and track patient progress over time.

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Initial Consultation Practitioner: Thomas Kelly Created: 1 November 2024, 10:00 AM Last updated: 1 November 2024, 10:30 AM Presenting Complaint: S: Localised pain in the lower back, right side Q: Dull and throbbing I: 7/10 at worst, currently 5/10 R: Pain radiates to the right hip T: Intermittent, worse in the morning AGG: Sitting for long periods, bending forward REL: Lying flat, applying heat Complaint History: ONSET: 2 months ago MOI: Lifting a heavy box CHRONO: Worsened over the past month PREV TTT: Physiotherapy sessions, chiropractic adjustments PREV INVEST/IMAGING: MRI scan showing mild disc bulge Past Medical History: PREV EPS: Similar episode 1 year ago ACC/INJ: None ILLNESSES: Hypertension MEDN: Lisinopril 10mg daily OPERATIONS: Appendectomy 5 years ago LEISURE: Regular swimming GOALS: SHORT: Reduce pain to 3/10 within 2 weeks INTERMED: Improve mobility and reduce stiffness LONG: Full recovery and return to normal activities Assessment: EXAMINATION: Tenderness in the lumbar region, reduced flexion RESTRICTED: Forward bending HT: Positive straight leg raise test PALP: Muscle tightness in the lumbar paraspinals SPECIAL TESTS: Negative for neurological deficits DIAGNOSIS: DX: Lumbar strain with mild disc bulge WORKING DX: N/A DDX: Sciatica, lumbar spondylosis INVEST: None required at this time Treatment: ST: Soft tissue massage to lumbar region ARTIC: Mobilisation of lumbar spine MET: Applied to lumbar paraspinals HVLA: None DN: None Treatment Plan: TTT FREQ & DUR: Twice weekly for 4 weeks, review after ADVICE: Avoid heavy lifting, maintain good posture REHAB: Core strengthening exercises Further Information: Patient advised to monitor symptoms and report any changes.