CLINICAL ASSESSMENT

REASON FOR ASSESSMENT
Question asked:
Referred by:

SOURCES REVIEWED
Document and date:

PRESENTING COMPLAINT
Presenting complaint:

HISTORY OF PRESENTING COMPLAINT
Onset and duration:
Site, character and radiation:
Triggers and relieving factors:
Associated symptoms:
Red flags asked about, present or absent:

PAST HISTORY, MEDICATIONS AND ALLERGIES
Past medical history:
Medications and doses:
Allergies and reactions:

FAMILY AND SOCIAL HISTORY
Family history:
Smoking, in pack-years:
Alcohol:
Occupation and function:

EXAMINATION AND INVESTIGATIONS
Examination:
Results, with value, unit and date:

ASSESSMENT
Working diagnosis:
Confidence:
Differential, ranked, with for and against:

PLAN
Investigations requested and who follows up:
Referrals and the question asked:
Medication decisions:
Safety-netting advice given:
Follow-up: