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Name/DOB/Age:

HPI (O L D C A R T S):

PMH (with years):

PSH (complications):

Meds (dose, regimen):

Allergies (with reaction):


FH (parents, siblings, extended family):

SH:
Living:
Tob/Alc/Drugs:
Job/Education:
Sex/STDs/IPV:
Diet:
Exercise:
Stress/Support:
ROS:
Gen: fever chills appetite/weight change headache
Skin: rashes sores moles itches
Eyes: pain vision loss blurriness double vision
Ears: pain hearing loss ringing
Nose: change in smell sinus pain congestion
Throat: sores sore throat hoarseness
Pulm: cough sputum wheezing pain sleep probs
Card: chest discomfort SOB PND orthopnea
palpitations edema lightheaded fainting
GI: abd pain diarrhea constipation heartburn blood
GU: freq urge pain blood stream incontinence
Gyn: abn menses dyspareunia discharge sores
MSK: myalgia arthralgia cramps stiff
Vasc: claudication varicose veins telangiectasias
Neuro: weak numb tingling paralysis memory loss
Heme: bruising bleeding petechiae
Endocrine: cold/heat intol polydipsia polyuria
Psych: mood swings depressed worry interest
PE (strike means abnormal):
Vitals: Temp
HR
RR
BP
Gen: NAD, well groomed, description
Skin: Warm, dry, well-perfused. No rashes or ulcers.
HEENT: PERRLA, EOMI, moist membranes, anicteric
Neck: no palpable nodes in _ chains, thyroid nonpalpable
Lungs: sym excursion, auscultation, percussion, fremitus
Card: S1 S2 normal, no murmurs/rubs, no thrills, JVD
absent, no edema, pulses present
Abd: sounds, nontender, liver nl, spleen nl, no bruits
MSK: knees, shoulders, ROM, no tenderness
Neuro: A&Ox3, all strength 5/5, finger-nose nl, romberg,
sensation, reflexes nl, CNs intact, normal gait
Psych: Affect