Allied Health Initial Assessment

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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™

Mall

Allied Health Professional Initial Assessment

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

Presenting Problem:
[Description of primary concern or reason for assessment]
[Onset, duration, and progression of symptoms]
[Impact on function and daily activities]

Relevant Medical History:
(hyphenated list)
- [Past medical conditions]
- [Previous surgeries or hospitalizations]
- [Relevant injuries]
- [Other pertinent health information]

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

Allergies:
(hyphenated list)
- [Allergen and reaction]
- [No known allergies if applicable]

Social History:
(hyphenated list)
- [Living situation]
- [Support systems]
- [Occupation and work status]
- [Hobbies and interests]
- [Tobacco, alcohol, recreational substances use]

Functional Assessment:
(hyphenated list)
- [Mobility status]
- [Transfers]
- [Activities of daily living (ADLs)]
- [Instrumental activities of daily living (IADLs)]
- [Use of assistive devices]
- [Communication abilities]
- [Cognitive status]
- [Pain assessment]

Physical Examination / Observations:
(hyphenated list)
- [Relevant physical findings]
- [Posture, gait, balance]
- [Range of motion]
- [Strength]
- [Sensation]
- [Other system-specific findings]

Assessment:
[Summary of key findings]
[Clinical impression or diagnosis if applicable]

Plan:
(hyphenated list)
- [Interventions recommended]
- [Goals of therapy]
- [Education provided]
- [Referrals to other services]
- [Follow up plan]
- [Return precautions or instructions]