UK History Template

History: - [describe current issues, reasons for visit, discussion topics, history of presenting complaints etc] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe past medical history, previous surgeries] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [mention medications and herbal supplements] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe social history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [mention allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Examination: - [describe general appearance and vital signs] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe findings from head and neck examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe findings from cardiovascular examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe findings from respiratory examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe findings from abdominal examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe findings from musculoskeletal examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe findings from neurological examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe findings from skin examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Diagnosis: - [list primary diagnosis] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [list secondary diagnoses] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [list differential diagnoses] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Plan: - [describe treatment plan, including medications, therapies, and lifestyle modifications] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe follow-up plans and referrals] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [mention patient education and counselling provided] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [mention any diagnostic tests or procedures ordered] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)