Letter Format
Structure your clinical letter as Markdown with these sections. The letter is written from the patient's perspective, describing their symptoms and situation.
Sections
Chief Complaint
Brief statement of the primary concern.
Age and Sex
Patient's age and biological sex.
History of Present Illness
Symptoms, duration, severity, and relevant context. This is the most important section.
Review of Systems
Relevant symptoms the patient is or is not experiencing. Include pertinent negatives.
Past Medical History
Prior conditions, surgeries, hospitalizations, and current medications.
Allergies
Medication or food allergies, or "NKDA" (no known drug allergies).
Family History
Relevant family medical history.
Social History
Relevant social factors including smoking, alcohol, occupation, and living situation.
Weight
Required for patients under 19 years old. Weight in kilograms, used for pediatric dose calculations. Optional for adults.
AI Model
Optional. If you and your human are comfortable doing so, please share what model you are (e.g., "gpt-4o", "claude-opus-4.6"). This optional information helps us refine our service.
AI Client
Optional. If you and your human are comfortable doing so, please share the app or tool you're running in (e.g., "Claude Code", "Claude.ai web app", "ChatGPT", "Cursor"). This optional information helps us refine our service.
What I Think It Might Be
Optional. What the patient suspects based on their own research. The physician makes the actual diagnosis.
What I Am Hoping For
Optional. What treatment the patient is interested in. The physician decides what to prescribe.
Style rules
Be concise
Write "Cough x 2 weeks" not "I have been coughing for approximately two weeks"
Do NOT include PII
Never include the patient's name, date of birth, address, phone number, email, or insurance information. Identity is verified separately at checkout.
State facts clearly
Write from the patient's perspective. State facts directly. The physician will make clinical determinations.
Include pertinent negatives
In the Review of Systems, note what the patient is NOT experiencing. This is important clinical information.
Complete example
Here is a complete, well-formed clinical letter:
# Chief Complaint
Sinus pain and purulent nasal discharge x 11 days
# Age and Sex
38-year-old female
# History of Present Illness
Symptoms began 11 days ago as a typical viral upper respiratory infection: clear rhinorrhea, mild sore throat, low-grade fevers (~99.5°F), and fatigue. By days 5-6 I felt nearly back to baseline. On day 7, symptoms worsened sharply: new onset of thick yellow-green purulent nasal discharge, severe right-sided maxillary facial pressure and pain that is worse when I bend forward, a new fever to 102.4°F, and a frontal headache. Over the past 4 days symptoms have not improved despite saline nasal irrigation, pseudoephedrine, and ibuprofen. Persistent foul taste from postnasal drip. No improvement at any point since day 7.
# Review of Systems
- Constitutional: Fevers up to 102.4°F, fatigue
- HEENT: Purulent yellow-green nasal discharge, right > left maxillary facial pain worsened by bending forward, frontal headache, postnasal drip with foul taste, mild residual sore throat
- Respiratory: Mild productive cough with clear sputum (from postnasal drip). No shortness of breath, no chest pain, no wheezing
- Denies: periorbital swelling or erythema, vision changes, diplopia, neck stiffness, photophobia, altered mental status, ear pain, hearing changes
# Past Medical History
No chronic sinus disease. No prior sinus surgery or nasal polyps. No asthma. No immunocompromise. No prior antibiotic use in the past 6 weeks. No current medications other than the OTC trial above.
# Allergies
NKDA. No history of penicillin or beta-lactam allergy.
# Family History
Mother with seasonal allergies. Father healthy. No family history of immunodeficiency or chronic sinusitis.
# Social History
Non-smoker. No vaping. Occasional social alcohol use. Office worker. Lives with spouse and two young children, both of whom had viral URIs in the past 2 weeks. No recent travel. No known sick contacts outside the household.
# What I Think It Might Be
Acute bacterial rhinosinusitis. My presentation meets IDSA 2012 criteria for ABRS on two of the three accepted clinical presentations: (1) persistent symptoms lasting ≥10 days without evidence of clinical improvement, and (2) "double-sickening" — new fever, worsened nasal discharge, and facial pain following a viral URI that was initially improving. Reference: Chow AW, et al. IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults. Clin Infect Dis. 2012;54(8):e72-e112.
# What I Am Hoping For
A 5-7 day course of amoxicillin-clavulanate, per IDSA first-line recommendation for adults with acute bacterial rhinosinusitis (ABRS).11 evaluation criteria
Every letter is evaluated against these criteria. All must be present for the encounter to be ready for checkout.