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ID:
Name

Age

Gender

Hospital number

Major Illnesses DM
Stroke/TIA
Lung

HTN
Liver

Lipids
Kidney

CAD
CHF

MEDICAL HX: Hospitalizations and major medical problems:

Diagnosis
Date
Presentation
Treatment
Sequelae

Thyroid
CA
Hospitalizations

CC:
HPI: Characterization of symptoms: when did you first feel unwell?
Symptom +
Onset/chronology
Duration
Quantity (1-10)
Location
Provoked?
Timing + Freq
Severity

MEDS:

Quality

Aggravating
Factors

Alleviating
Factors

Dose

Freq

Route

Since when

Side Effects

Associated Sx/
RF

ALLERGIES:

course of sx
radiation

progression since onset

personal hx

Health maintenance:

PAP

Lipids

LDL

mammogram

FOBT/Scope

PSA

constant vs. intermittent

function/quality of life
TC

HDL

TG

Fasting glucose

DEXA

Immunizations:
Infectious illnesses: measles, mumps, rubella, DPT, chickenpox, scarlet fever
rheumatic fever, pneumonia, TB, hepatitis
Injuries/disability:
System-related ROS:

Recent travel:

SOCIAL HX:
Occupation:

Hometown:

Partner:
REVIEW HPI Is there anything else you would like to tell me?
IMPRESSION:
1.

Children:

PLAN:
1.

Smoking

EtOH

Drug Use

Diet?

Exercise?

Caffeinated beverages?

SEXUAL HX: Sexually active?

Y N
Men, women, or both?
Having any concerns? Frequency ,
type,
satisfaction with intercourse
age at 1st intercourse_____
number of partners______
G ___ P_____
FAMILY HX: age, current health, major illnesses, cause of death
Father
Mother
Grandparents

Siblings

PMH:
General:
CAD?
SURGICAL & OB :
Type
Date

Complications

Result

CANCER?
DM?

CHF?

HTN?

COPD?
Thyroid?

Lipid disorder?

Asthma?

GI?

STROKE/TIA?
Kidney?

CNS/PNS (seizure, paralysis)?

Arthritis?
Psychiatric?

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ROS:
GENERAL fevers, chills, sweats; weight +/- ; D in appetite;

PHYSICAL EXAM: **wash hands**

fatigue

VITAL SIGNS: T______

ht. ______ wt.__________ BMI _________ Pain______ Pulse ox _____%

SKIN rashes, lesions , sweating, pruritis, easy bruising, difficult healing

swelling,

petechiae,

photosensitivity,

changes in hair or nails

P____ RR____BP __________

GENERAL: __________________________________________________________
SKIN:______________________________________________cap refill__________

HEAD / NECK headache,

EYES

dizziness,

vision changes; glasses,

inflammation/discharge,

trauma,

blurring;

dry eyes,

EARS hearing loss,

pain,

swollen LNs

diplopia;

scotoma,

tinnitus,

pain

photophobia

vertigo;

drainage

clubbing____________cyanosis_______________edema ____________________
HEAD: NC/AT________________________________________________________
face___________________________________CN V __________VII _________
EYES: conjunctiva____________________________EOMI____________________
VFI___________________________PERRLA _____________________________
ophthalmoscopic _____________________________________________________
EARS:

NOSE epistaxis,

discharge,

sneezing;

obstruction,

chronic sinusitis

TMs__________________________hearing_________________________

NOSE:_______________________________________________________________
THROAT: _____________________________ palatal elev_______ gag reflex_____

MOUTH/ THROAT
dry mouth,

teeth,

gums,

trouble swallowing,

oral ulcers,

hoarseness,

pain
sore throat

NECK:__________________________LNs ________________________________
Carotid pulses ___________________________ bruits ______________________

CV chest pain or pressure,

palpitations,

exercise tolerance, fatigue, circulatory probs;

edema,
murmurs,

syncope

Thyroid____________________________________________________________

claudication

LUNGS: inspect_______________________________________________________
auscultate__________________________________________________________

LUNGS dyspnea on exertion;

asthma or wheezing;

cough,

cyanosis,

nausea / vomiting,

reflux or heartburn,

diarrhea

dysphagia,

hematemesis;

PND

change in appearance,
odynophagia;

loss of appetite,

abdominal pain;

hemoptysis

orthopnea,

BREASTS pain, masses, discharge,

GI

sputum,

dyspepsia

food intolerance

jaundice,

constipation;

self-exam

change in bowel habits

melena ,

hematochezia

percuss ( w/ diaph excursion)___________________________________________

CV: palpate PMI ______________________________________________________
auscultate @ 4 areas w/diaphragm: rate & rhythm, murmurs, rubs, gallops, clicks
_____________________________________________________________________
check for aortic insufficiency (LSB w/ pt forward in exhalation)________________
Pt. LYING DOWN:
CV: Auscultation @ BASE and LSB_______________________________________
LL DECUBITUS: apex _______________________________________________
JVP_______________________________________________________________
ABDOMEN:__________________________________________________________

GU obstructive symptoms,

dysuria,

frequency,

hematuria, pyuria, previous UTIs; discharge,

nocturia,

urgency
incontinence

_______________________________________ bowel sounds_______ bruits______

percuss______________________liver span ______________________________
palpate____________________________________________________________

MENSTRUAL menarche; last period, length of cycle, duration of flow

how regular,

how heavy;

pain w/ menstruation or intercourse

PULSES: dorsalis pedis ____________ posterior tibial _________edema_________

femoral pulse ( + auscultate)____________________________________
LE MS exam: ________________________________________________________

vaginal bleeding or discharge,

intermenstrual bleeding; age of menopause

Pt. SITTING: CVA tenderness____________________________________________

ENDOCRINE thyroid, adrenal, hormonal;

osteoporosis;

edema,

polyuria,

temperature intolerance;
polydipsia,

polyphagia

UE MS exam: wrists _______________________elbows______________________

shoulders ____________________ neck ________________________
NEURO: Mental status____________________________CNs__________________

MS
swelling,

arthralgias,
erythema,

arthritis,
tenderness;

ROM,

stiffness,

gout,

myalgias

neck or low back pain

Sensation: touch_________ pain_________ position_________ vibration_______

Reflexes: biceps_________ brachioradialis ___________triceps_______________
patellar_________achilles___________________babinski______________
Cerebellar: finger tapping________________ heel to shin____________________

NEURO syncope,
numbness / tingling,

vertigo,
weakness,

LOC,
equilibrium,

seizures
coordination/gait

Pt. STANDING
Spine: _______________________________________________________________

depression:

UE drift_________________________ Romberg _____________________________

interest, guilt, energy, sleep, concentration, appetite, psychomotor, suicide

Gait and station______________ swing and stance______ heel / toe walking_______

PSYCH anxiety;

mania;

memory loss,