Chiropractor Initial Consultation Appointment

Subjective: Current Symptoms: [Description of the current symptoms] (Describe the patient's current symptoms in detail, including onset, duration, and characteristics of pain or discomfort. Note the location, type, and whether the pain radiates. Include details about what increases or decreases the pain. Only include if explicitly mentioned in transcript or context, else omit section entirely.) - Started [start date or event], due to [triggering factor]. - Since onset: [describe symptom progression since onset]. - Pain is located at [location], is [character of pain] in character, does not radiate / radiates to [radiation location]. - Pain increased by: [factors increasing pain]. - Pain decreased by: [factors decreasing pain]. Review of Systems: - Bowel & Bladder: [describe any changes or abnormalities]. - Numbness: [areas affected, onset, duration, aggravating/relieving positions]. - Weakness: [location and functional impact]. - P&N's: [pins and needles distribution, duration, triggers]. - SOB (shortness of breath): [include triggers, frequency, and severity]. - Headaches: [frequency, location, intensity, associated symptoms]. - Dizziness: [timing, triggers, duration]. (Note any other relevant systems if mentioned in transcript or context.) History of Present Illness: [Patient’s history related to current issue, including prior episodes, intensity, and context.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - Previous episodes: [when, how often, context]. - First episode: [timing, presentation]. - At its worst: [severity and functional impact]. - Stressors: [emotional, work-related, or contextual factors]. - Family situation: [living arrangements, dependents, support system]. Past Medical and Surgical History: [Musculoskeletal, spine, or joint conditions and surgeries] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - Previous treatments: [e.g. physio, chiro, meds]. - Previous diagnoses: [formal diagnoses, if known]. - Scan/MRI/X-ray results: [relevant imaging]. - Pregnancy history: [number of births, birth type]. Lifestyle Factors: [Lifestyle habits relevant to health and MSK load] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - Working conditions: [seated/standing, repetitive movements, load handling]. - Activity limitations: [activities unable to perform that are meaningful to the patient]. Current Medications: [Name, dose, frequency, route of medications or supplements] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Family History: [Family history of MSK, spinal, or systemic conditions] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Red Flags: [Include any red flags: unexplained weight loss, fever, trauma, history of cancer, neurological symptoms, night sweats, DVT history, etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) The Why – Goal of Care: [Patient’s stated goals for care or activities affected by their condition, such as work, home tasks, caregiving, or exercise.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Objective: Assessment of Neurological Function: [Document reflexes, sensory testing, dermatomes, motor strength, coordination, dizziness or balance impairments] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Vitals: [Blood pressure, heart rate, respiratory rate, temperature] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Physical Examination Findings: [Findings from general movement, posture, and specific SFMA-based or chiropractic functional assessments] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - Cx flexion: - Cx extension: - Cx rotation L: - Cx rotation R: - GH pattern 1 (IntRot, extension) L: - GH pattern 1 (IntRot, extension) R: - GH pattern 2 (ExtRot, flexion) L: - GH pattern 2 (ExtRot, flexion) R: - MS flexion: - MS extension: - MS rotation L: - MS rotation R: - Single leg balance L: - Single leg balance R: - Deep squat: - Gait analysis: Results of Diagnostic Tests: [Summarise any reviewed imaging or diagnostic test findings relevant to case] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Initial Thoughts, Diagnosis, and Plan: Initial Thoughts: [Functional diagnosis or chiropractic impression based on clinical assessment] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Areas identified for chiropractic adjustment or mobilisation] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Patient Expectations: [What the patient expects or believes is the issue and expected timeline for resolution] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Detailed Treatment Plan: [Proposed management including chiropractic techniques, exercise rehab, mobilisation, or adjunctive tools like dry needling, taping, etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - Emphasis on team effort and rehab consistency. Frequency and Duration of Treatment: [Suggested treatment frequency and planned duration] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Goals of Treatment: [Short- and long-term goals, e.g. return to lifting, sitting tolerance, sport participation] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Self-care Recommendations: [Home exercises, posture changes, sleep advice, load management instructions] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Referrals: [Referrals for imaging, orthopaedics, physio, biokinetics, psychology, etc.] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Intervention / Actions: Treatment Provided: [Summary of intervention during this consultation] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Details of Interventions: [Manual therapy techniques, manipulations, soft tissue release, or other modalities used] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Patient Response to Treatment: [Patient-reported or observed response, including improvements or sensitivity] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Patient Education: [Information shared on ergonomics, lifestyle modifications, recovery expectations, and preventive care] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Family and Social Information: [Patient’s family context or support network as discussed] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Upcoming Events: [Any mentioned upcoming travel, events, or sport that may affect treatment plan] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Referral Path: [Referral source (e.g. friend, GP, physio, returning patient), or link to other clinic patients] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Clothing Instructions: [Instructions given about appropriate clothing for future visits] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Follow-up and Continued Care: [Details about next session, frequency, or tapering plan] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Patient Concerns and Preferences: [Any specific concerns about therapy, preferences for technique, or sensitivity discussed] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Alterations to Plan: [Changes made to initial care plan based on new findings or patient preferences] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Focus for Next Appointment: [Primary area or function to be re-evaluated or addressed next visit] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Internal Referrals: [Referral to in-house biokineticist, massage therapist, or another chiropractor] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) (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 that the information has not been explicitly mentioned in your output. Just leave the relevant placeholder or section blank if not explicitly mentioned. Use as many full sentences as needed to capture all the relevant information from the transcript.)