Patient record templates by specialty

Dental

The dental template has seven sections, from medical history to the record of treatments, with an FDI tooth chart the dentist draws findings on, and the allergy and pregnancy questions marked as safety-critical. The sections one by one, the chart and the X-rays are explained on the page for dental clinics.

• Dental clinic software

Physiotherapy

Built for physiotherapy practices. Pain is scored on the VAS scale at the first visit and again after every session, so progress shows in one table. The record's sections and the session log are explained on the physiotherapy page.

• Physiotherapy clinic software

Dermato-aesthetics

For aesthetic and dermatology clinics. The treatment record keeps the batch (LOT) number of every product, so a reaction can be traced back to the exact vial used.

• Skin assessment: Fitzpatrick type, skin type and main concern
• Medical history: allergies, autoimmune conditions, keloids, cold sores, isotretinoin in the last 6 months and pregnancy
• Photographic documentation before and after treatment
• Consent to an aesthetic procedure
• Treatment record: product, batch number, area, amount, reactions and next treatment due

General practice

For GPs in private practice. Vital signs are kept in a table, one row per measurement, so changes show from one visit to the next.

• Reason for the visit and history of the present illness
• Vital signs: blood pressure, heart rate, temperature, SpO₂ and weight
• Medical history: blood pressure, diabetes, heart, breathing, thyroid, allergies, smoking, family history and surgery
• Medication: current treatment, dose, frequency and start date
• Examination, diagnosis, treatment plan, investigations and referrals
• Informed consent

Paediatrics

A child does not sign for themselves, so the template opens with the parent or guardian and closes with the guardian's consent, under their name.

• Parent or guardian: name, relationship to the child and phone
• Birth history: gestational age, birth weight, mode of delivery, complications and neonatal intensive care
• Growth and development: weight, height, head circumference and percentile by date, with developmental milestones
• Immunisation: vaccine, dose, date, batch number and reactions
• Medical history: allergies, asthma, hospital admissions, chronic conditions and family history
• Examination, diagnosis and plan
• Guardian consent

Gynaecology

For gynaecology and obstetrics, with the type of visit running from a routine check to pregnancy, family planning and menopause.

• Reason for and type of visit
• Menstrual history: menarche, last period, cycle, pain and contraception
• Obstetric history: gravida, para and a table of previous pregnancies
• Medical history: surgery, infections, family history, last cervical smear and allergies
• Examination and ultrasound, with the image, date and findings
• Diagnosis, treatment plan and follow-up
• Informed consent

Ophthalmology

Visual acuity and refraction are kept in tables with one row for each eye, OD and OS, so the values read side by side.

• Reason for the visit, the affected eye, and glasses or contact lenses
• Visual acuity uncorrected, corrected and with pinhole
• Refraction: sphere, cylinder, axis and add
• Examination: intraocular pressure, anterior segment, fundus and a fundus photograph
• Medical history: glaucoma, diabetes, eye surgery, family history and allergies
• Diagnosis, prescription and treatment plan
• Informed consent

Orthopaedics

From the injury to rehabilitation: the body map, the range of motion and strength measurements and the imaging stay on the same record.

• Injury: complaint, date, mechanism, a VAS pain score of 0-10 and the affected side
• Examination: body map, inspection and palpation, range of motion and strength, special tests and neurovascular status
• Imaging: X-ray, ultrasound, MRI or CT, with the image and findings
• Medical history: surgery, fractures, osteoporosis, arthritis and allergies
• Diagnosis, treatment plan and rehabilitation
• Informed consent

Psychology

The risk assessment has a section of its own, left open so it is found at once. The consent to therapy explains confidentiality and its limits, not the risks of a procedure.

• Initial assessment: presenting problem, referral, history, previous treatment and medication
• Background: family, work or study, sleep, and alcohol or substance use
• Risk assessment: risk level, suicidal thoughts, self-harm, risk to others and a safety plan
• Formulation and goals, with the therapeutic approach: CBT, psychodynamic, systemic, humanistic, EMDR or integrative
• Confidentiality and consent to therapy
• Session notes: main theme, risk and homework

Nutrition

For nutritionists. Measurements are kept in a table by date, so weight can be followed from one appointment to the next.

• Goal: weight loss, gain or maintenance, sports performance or managing a condition
• Anthropometrics: height, weight, BMI, waist, body fat and muscle mass
• Medical history: diabetes, thyroid, gastrointestinal problems, food allergies and eating disorders
• Dietary habits: a 24-hour recall, water and physical activity
• Nutrition plan: daily calories, meal plan and recommendations
• Informed consent

Change a template to fit your clinic

A template you take from the gallery becomes yours and is no longer tied to the original. Before you use it, remove the questions you do not need, add the ones that are missing, rename sections and edit the consent wording. While you work, a live preview shows how staff will fill the record in.

The pregnancy question does not appear on a male patient's record, a section can close by itself when its first question is answered No, and any yes or no question can be marked safety-critical. When you take a template, a patient privacy notice with the clinic's name and contact details is added at the end, as a draft for you to read and adapt.

You can also build a template from scratch, with these kinds of field:

• Number, date and time
• Short or long text
• A dropdown list
• Yes or No, with a note when the answer is Yes
• A table with rows added as needed
• A photo, or one diagram shared by every patient to draw on
• A consent statement signed by the patient and the doctor

Have your own form on paper? We turn it into a template

If the clinic already has a form that works, photograph a blank copy, front and back, and send it to us from inside the software, as a support request, or on WhatsApp or by email. We type it up as a template and it waits in your account, at no charge. Send only the blank form, never a filled-in record.