History & Physical

Hi Good morning. My name is Bryan Coronel. I am Family Nurse Practitioner

Student attending at University of Phoenix. Today I am with Dr. Porter doing my
clinical experience. I have been a Registered Nurse for the past 4 years and have
gone back to school to obtain additional learning.
Today Dr. Porter has asked me to start by gathering your history of why you came
in today and do the appropriate physical exam. Then I will momentarily go out to
present my findings and we will discuss with your plan of care. Dr. Porter will also
ask you questions and recheck my exam. I will be taking down important notes as
I proceed with my physical exam so that I will not miss any information regarding
your care.
Do you have any questions?
how can I help you today?
CC:
HPI: USE POLDCARTS
PMH:
Childhood illness:
Major adult illness:
Immunizations:
Surgery:
Serious Injuries
Limitations:
Transfusions
Medications:
1. Past______________________
2. Recent____________________
3. Home remedies______________
FamHx:
Any relatives with similar condition:____
Immediate family: Mom____Dad____
Hystory of disease:
Spouse Name:
Children (age & health status)
SocHx:
Marital status:
Occupation:
Nutrition and diet: (drugs, alcohol, caffeine)
Exercise:
Sexual history (concern with sexual feelings and performance)

Religion:
Complementary alternative medication:
Form of relaxation:
Pets:
Recent travel:
P
O
L
D
C
A
R
T
S

Prveious
Similar
occurance
Onset
location
Duration
Characteristics
Aggravating
Relieving
Temporal
Severity

Allergies:
ROS:
GEN: Can you tell me in general how is your overall general health?
HEENT:
headache_____________________________________
vision problem_________________________________
dental________________________________________
hearing_______________________________________
nasal and oral cavity_____________________________
CARDIO:
chest pain____________________________________
hypertension__________________________________
hyperlipidemia_________________________________
edema_______________________________________
PULM:
cough (color, consistency)_________________________________
wheezing____________________________________
any exposure to chemicals?_____________________
GI:
Weight loss or gain_________________________________
NVD_____________________________________________
constipation_______________________________________

bleeding__________________________________________
abd pain__________________________________________
appetite__________________________________________
difficulty swallowing_________________________________
hemorrhoids_______________________________________
hepatitis__________________________________________
GU:
difficulty urinating___________________________________
any bleeding_______________________________________
increased frequency_________________________________
ENDO:
any increase in urine_________________________________
Thirst_____________________________________________
do you get hungry all the time__________________________
Do you getl easily get cold or hot? ______________________
HEME: easily bruised? ___ ____________________________
fatigue_____________________________________________
fever______________________________________________
chills______________________________________________
night sweats________________________________________
Rheum:
Joint stiffness or swelling____________________________
Gout______________________________________________
Back pain__________________________________________
DERM: rashes___
skin dryness____
itching___,
lumps___
changes in nails or hair_____
NEURO:
Dizziness__________________________________________________
Syncope___________________________________________________
Weakness__________________________________________________
Problems with remembering or memory_________________________
PSYCH:
Depression__________________________________________________
Panic/Anxiety________________________________________________
Hallucinations________________________________________________
If female:
Menses:
Regularity:____duration____amount_______LMP______infertility_____
Any contraceptives:_________
Pregnancies #children______,living____, miscarriage___abortion____

Type of delivery_____
Any complications during pregnancy___________ Postpartum period______
Conclusion statement:
Is there anything else you that we missed that might be important for me to know?
If there several problems, which one is the most concerning?
If my history is vague or complicated: What do you think worries you the most?

Assessment:
Differential Diagnosis:___________
Plan: