Consult Letter

Chief Complaint

Template

Thank you for your referral of [patient's full name] for Family Medicine Consultation. [he/she/they] was seen in person on [appointment date]. Reason for Visit: [reason for visit] History of Present Illness: [patient's full name] reports a [duration] history of [symptoms]. Initially, the [symptom description]. Over the past [timeframe], it has [symptom progression]. [He/She/They] has also experienced [additional symptoms]. [Patient's full name] mentioned [specific details about symptoms, e.g., fever, chills, etc.]. [Optional: Include relevant social history, e.g., smoking, alcohol use, etc.]. Medical History: [medical history] Current Medications: [current medications] Allergies: [allergies] Family and Social History: [family and social history] Vital Signs: [vital signs] Physical Exams: [physical exam findings] Investigations: [relevant investigations] Impression and Recommendations: 1. [diagnosis and ICD code]: [summary of diagnosis and reasoning]. - Plan: - [evaluation plan] - [diagnostic tests or imaging] - [treatment or lifestyle recommendations] - [follow-up instructions] Surgery Discussion: [Optional: surgery discussion or "Not applicable."] I recommend [patient's full name] follow the outlined plan and return for follow-up if [his/her/their] symptoms persist or worsen. Thank you for the opportunity to assist in [his/her/their] care. Sincerely, [doctor's full name] [medical facility name]