HumanisRx- Initial Consultation

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

MedCheckUp - INITIAL CONSULTATION

PATIENT INFORMATION
(hyphenated list)
- First Name: [First name]
- Last Name: [Last name]
- PID: [Patient ID]
- Date of Birth: [Date of birth]
- Age: [Age]
- Consultation Date: [Consultation date]
- Method: [Method of consultation]
- Interviewed: [Person interviewed]
- Reasons for Referral: [Reason(s) for referral]

Consultation Date: [Date]
Method: [Method: Phone / In-person / Virtual]
Interviewed: [Patient / Family / Other]

HISTORY OF PRESENTING ILLNESS
[Description of presenting complaint, including onset, duration, associated symptoms, and relevant history]

LABS
Height: [Height in cin]
Weight: [Weight in lbs]
BMI: [BMI value and obesity class if applicable]
Systolic BP: [Systolic BP in mmHg]
Diastolic BP: [Diastolic BP in mmHg]
HR: [Heart rate in bpm]
Relevant lab values: [List relevant lab results with units]

IMMUNIZATION STATUS
Influenza: [Yes / No] Last given: [Date]
Shingles: [Yes / No] Last given: [Date]
COVID-19: [Yes / No] Last given: [Date]
Pneumococcal: [Yes / No] Last given: [Date]

IF FEMALE (only include this section if female)
Pregnant:] [Yes / No]
Breastfeeding: [Yes / No]

LIFESTYLE
Alcohol: [Amount and frequency]
Tobacco: [Amount and frequency]
Caffeine: [Amount and frequency]
Recreational substance use: [Type, amount, frequency]

Physical Activity Vital Sign (PAVS)
1. On average, how many days per week do you engage in moderate to strenuous exercise (such as a brisk walk)? [Number of days]
2. On average, how many minutes per day do you engage in exercise at this level? [Number of minutes]
[Physical activity comments]

Sleep
Average hours/night: [Number of hours]
[Sleep comments]

Past History
Substance use disorder: [Yes / No / Details]
Mental health disorder: [Yes / No / Details]

Patient Perception of Health
Would you say your health today with your condition is: [Terrible / Poor / Average / Good / Excellent]
In the last 2 weeks, how much did your [chief complaints] interfere with your normal activities? [Not at all / A little bit / Moderately / Quite a bit / Extremely]

GOALS OF THERAPY

Depression/Anxiety:
(hyphenated list) (include only what is mentioned)
Acute Phase:
- [Achieve remission of depressive symptoms]
- [Prevent suicide]
- [Restore functioning]
Maintenance Phase
- [Prevent recurrence]
- [Minimize work absence]
- [Return to baseline function]
- [Return to baseline quality of life]
- [Improve sleep]
- [Reduce as-needed use of:]

Pain:
(hyphenated list) (include only what is mentioned)
- [Reduce pain severity] (e.g., pain score)
- [Reduce pain frequency]
- [Prevent chronicity]
- [Improve physical function] (ex. ROM, walking)
- [Reduce/discontinue opioid]
- [Reduce healthcare utilization]
- [Minimize work absence]
- [Increase physical activity]

Pharmacist Name: [Pharmacist name]
Licensing Province: [Province]
License #: [License number]
Documentation Completion and Sent Date: [yyyy-mm-dd]
Consultation Duration: [Minutes]