Physiology Consultation Note

Template structure

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

Physiologist Note

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

History of Present Illness:
[Description of presenting symptoms, onset, duration, progression, and any relevant triggers or alleviating factors]
[Relevant associated history, including previous interventions, therapies, or diagnostic findings]

Past Medical History:
(hyphenated list)
- [Chronic illnesses]
- [Previous surgeries]
- [Relevant hospitalizations]

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

Allergies:
(hyphenated list)
- [Drug allergies]
- [Other allergies]

Family History:
(hyphenated list)
- [Relevant familial conditions]

Social History:
(hyphenated list)
- [Tobacco use: type, amount, duration]
- [Alcohol use: type, amount, frequency]
- [Recreational substances]
- [Occupation]
- [Living situation]

Physical Examination:
(hyphenated list)
- [Vital signs with units] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [General appearance]
- [Relevant system-specific findings] (e.g., Cardiovascular: findings, Respiratory: findings, Neurological: findings, Musculoskeletal: findings)

Investigations:
(hyphenated list)
- [Completed investigation results with units] (e.g., ECG, spirometry, exercise tolerance test, lab results)

Assessment:
(hyphenated list)
- [Summary of findings]
- [Diagnosis or differential diagnosis]
- [Functional status or limitations]

Plan:
(hyphenated list)
- [Further investigations planned or ordered]
- [Therapeutic interventions or recommendations]
- [Lifestyle or exercise counselling]
- [Referrals to other specialists or allied health]
- [Follow up plan]
- [Return precautions]