HH MD Intake Assessment Template MASTER

AI Consent:
AI consent (provided verbally to writer in office today): I have discussed with my doctor how they use Empathia AI to make notes of our appointments. I have had the opportunity to ask questions about Empathia AI and receive answers. I consent to my physician using Empathia AI in the way described in this notice. I understand that if I change my mind, I must tell my doctor and they will stop using Empathia AI for my care. I understand that Empathia AI will retain any Transcripts and Notes that it made before I changed my mind, and may use them to improve Empathia AI's product and services. I consent to my physician using Empathia AI when providing me care.

Introduction:
Patient welcomed to Regional Medical Center. Collaborative team approach to healthcare discussed, with focus on lifestyle management and lifestyle change.
* What are your expectations in joining Regional Medical Center?
Patient demographics reviewed and updated.
Patient consents to receipt of results via email: .
Preferred pharmacy confirmed: .

* What health goals do you want to work on this year?

Clinician and Patient Expectations:
1. Discussed patient's expectations for care at Regional Medical Center
2. Ensuring patient understands the scope of care at Regional Medical Center from a primary care perspective regarding longitudinal coverage. Collaborative team approach to healthcare discussed, with focus on lifestyle management and lifestyle change.
3. Appropriate use of on-call system regarding urgency of issue
4. Appropriate use of pharmacy fax renewal for medications
5. Patients allowing care coordinators to understand the reason for their booked appointments to allow for appropriate time and triage
6. Ensuring patient understands the difference between same day and regular appointments, to ensure triage of issues and appropriate time for issue
7. Patient understanding of appropriateness of booking appointments in person versus telemedicine versus need to visit the ER
8. Ensuring effective two-way communication lines between the patient and physician

Subjective:
Chief Complaint:
Follow-up for diabetes and hypertension management

Medical History:
* Past surgical history: No significant findings.

* Past medical history: Type 2 diabetes mellitus, hypertension.

* Are you seeing any specialists? No significant findings.

* When was your last physical? No significant findings.

Family History:
FAMILY HX: (updates on: 2026-01-15)
Younger brother recently diagnosed with diabetes.

Allergies, Medications and Supplements:
* Do you have any allergies or intolerances? (medication, environment, or food): No known drug allergies.

* Current medications: Metformin, Ramipril. No side effects from metformin and ramipril.

* Current supplements or over the counter medications: No significant findings.

Immunizations and Travel History:
Current Immunizations record:
- dTap: 
- Annual flu: 
- Pneumonia vaccine(s): 
- Shingles: 
- HPV: 
- RSV: 
- Travel vaccines: 

* Travel plans? 

Social History:
* Social history notes updated on 2026-01-15

Relationships status: No significant findings.
Family: No significant findings.
Occupation: No significant findings.
Diet: Patient reports trying to eat better, focusing on high-fibre, low-glycemic foods, and limiting salt intake.
Caffeine: No significant findings.
Exercise: Patient reports walking more and is encouraged to add light strength training twice a week.
Alcohol: No significant findings.
Smoking: No significant findings.
Substances: No significant findings.
Sleep: No significant findings.
Stress: No significant findings.
Do you have a strong support network? No significant findings.

Health Prevention:
Age and health appropriate health prevention will be discussed with patient.

Dietary and Exercise Concerns:
* Dietary restrictions or concerns: Patient is advised to eat high-fibre, low-glycemic foods, avoid sugary drinks, and reduce sodium intake to about 1 teaspoon per day.

* Exercise routine or challenges: Patient is walking more and is encouraged to add light strength training twice a week.

Review of Systems:
No significant findings.

Discussion of Present Concerns:
Follow-up for diabetes and hypertension management. Patient is trying to keep blood sugars and blood pressure under control. No side effects from medications. No allergies reported.

PHYSICAL EXAM:
General: well appearing / body habitus / NAD 
Speaking in full and complete sentences with appropriate responses to questions, no forced or pressured speech
Ambulating independently fully weight bearing with alternating gait
Skin: no rash / no bruising / no prominent lesions / no varicosities ABCDE self skin assessment explained.
Eyes: normal sclera & conjunctiva / PERLA / full EOMs / fundi  
Ears: EACs clear / TMs normal 
Nose: mucosa non-inflamed / normal septum & turbinates 
Mouth: mucous membranes moist / no mucosal lesions / good dentition 
Pharynx: mucosa non-inflamed / no tonsillar hypertrophy or exudate 
Neck: supple / no adenopathy / thyroid non-enlarged & non-tender 
Vitals: Weight 84 kg, BMI 28.3, Blood pressure 138/84 mmHg
Heart: normal S1&2 / no S3&4 / no murmur / pulses strong, symmetric, normal rate & rhythm / no JVD / no peripheral edema / heart sounds normal
Lungs: clear to auscultation / no crackles or wheeze / good air entry to bases / lungs are clear
Abdo: normal bowel sounds / soft / non-distended / non-tender / no mass or HSM / no abdominal tenderness
Rectal: normal sphincter tone / no hemorrhoids or masses / no prostate enlargement 
MSK: normal gait & station
Neuro: A&Ox3 / CN II-XII grossly intact / power 5/5 upper & lower limbs / DTRs symmetric to upper & lower extremities / coordination & sensation intact / foot sensation intact
Psych: well groomed & dressed / good rapport / mood euthymic / bright affect / normal speech / cognition grossly intact / no thought or perceptual disturbance / I&J intact 
Pelvic: not examined / normal vulva / normal vaginal canal / no prolapse / normal cervix / Pap performed / no palpable abnormalities of uterus or adnexae on bi-manual / no atrophy 
Breast: not examined / no nipple or skin abnormality / no dominant masses / no tenderness to palpation / no axillary or supraclavicular adenopathy 
GU: not examined / no penile lesions / no discharge / bilateral testes & epididymes / no palpable scrotal abnormalities
No ankle swelling. No abdominal tenderness. No foot ulcers or skin issues.

DIAGNOSES:
Type 2 diabetes mellitus / Hypertension

Assessment and Plan:
Diabetes is stable with fasting glucose of 7.8 mmol/L and HbA1c of 7.2%. Blood pressure is slightly elevated at 138/84 mmHg but improved compared to previous visit. Lipid panel shows LDL at 2.4 mmol/L and triglycerides at 1.8 mmol/L. Patient is adherent to metformin and ramipril with no side effects. No known drug allergies. Patient is encouraged to continue dietary modifications, increase physical activity, and limit sodium intake. Referral to dietitian is provided for further guidance. Patient is advised to keep a log of home blood glucose readings and bring it to the next appointment. Repeat laboratory investigations are planned in 3 months.
- Continue current medications
- Maintain dietary and exercise regimen
- Limit sodium intake to 1 teaspoon per day
- Referral to dietitian
- Repeat laboratory tests in 3 months
- Bring home glucose log to next visit

Upcoming Appointment Notes:
* Reviewed upcoming appointment notes: Patient to repeat laboratory investigations in 3 months and bring home glucose log to next visit.