Exercise Physiology Consult Note

Finished note

Example — generated by Notat from a sample visit

Presenting concern:
Shoulder stiffness and discomfort with overhead reaching, developing gradually over six weeks.

Assessment:
Movement restriction affecting daily activity.

Plan:
Agreed a graded home exercise programme and activity modification. Review progress in three weeks.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Template

Exercise Physiologist Note

Patient Identification:
[Patient name, age, gender, relevant medical history or reason for referral]

History of Present Illness:
[Description of current symptoms, functional limitations, or reason for visit]
[Relevant history including onset, duration, progression, and previous interventions]

Past Medical History:
(hyphenated list)
- [Chronic medical conditions]
- [Previous surgeries or hospitalizations]
- [Relevant injuries]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]

Allergies:
(hyphenated list)
- [Drug, food, or environmental allergies]

Social History:
(hyphenated list)
- [Tobacco use: type, amount, duration]
- [Alcohol use: type, amount, frequency]
- [Recreational substances: type, amount, frequency]
- [Occupation and physical activity level]
- [Living situation and support system]

Physical Activity History:
(hyphenated list)
- [Current exercise routine: type, frequency, duration, intensity]
- [Previous exercise experience]
- [Barriers to physical activity]
- [Motivation and goals]

Physical Examination:
(hyphenated list)
- [Vital signs with units] (e.g., HR: # bpm, BP: #/# mmHg, T: #°C, RR: #, O2 sats: #%)
- [Anthropometric measurements: height, weight, BMI, waist circumference]
- [Musculoskeletal assessment: strength, flexibility, joint range of motion]
- [Cardiorespiratory assessment: endurance, functional capacity]
- [Other relevant findings]

Investigations:
(hyphenated list)
- [Completed laboratory or imaging results]
- [Exercise testing results: type, protocol, findings]

Assessment:
(hyphenated list)
- [Summary of functional status and limitations]
- [Relevant diagnoses or risk factors]
- [Readiness for exercise]

Plan:
(hyphenated list)
- [Exercise prescription: type, frequency, intensity, duration, progression]
- [Education and counselling provided]
- [Referrals to other providers if needed]
- [Follow up plan]
- [Return precautions or safety considerations]