Date and Time: Ears: denies pain, discharge, infections, tinnitus, changes in hearing,

injury, hearing aid, audiometry; date and provider name

ID: Age: ___ Gender: ___ Ethnicity: Insurance:
Nose: denies epistaxis, obstruction, airflow, discharge, frequent colds,
☐AD/Living Will ☐Copy olfactory changes, postnasal drip, sinus pain or infection.
☐Health Proxy: _______________ (relationship)
Mouth/Throat: denies bleeding gums, sores in mouth, toothache,
CC: “ changes in taste, dentures, sore throat, difficulty chewing or
swallowing, hoarseness, voice changes, date of last dental exam and
provider. ADL: Dental Hygiene.
HPI:
Neck/Nodes: denies pain, stiffness, masses, swelling, swollen glands

Breast/Axilla: denies lumps, discharge, pain, tenderness, dimpling,

contour changes, nipple changes

☐SBE: When, how often, last mammography, date and provider

PMH:
Respiratory: denies cough, sputum production, hemoptysis, chest pain,
shortness of breath, wheezing, asthma, bronchitis, pneumonia,
emphysema, date of last CXR, date of PPD and results.

Cardiovascular: denies chest pain or tightness, palpitations, dyspnea,

murmur, edema, paroxysmal nocturnal dyspnea, known heart
PSH: murmur, date of last EKG and results, date of cardiology consult and
provider.

GI: denies Anorexia, nausea, vomiting, dysphagia, indigestion,

SH: belching, heartburn, hematemesis, abdominal pain, ulcers, jaundice,
☐ ETOH (kind ______, amount _____ x day/week/month) food intolerance, diarrhea, constipation, change in bowel habits,
☐ Smoking ( ___PPD x ____ yrs) ☐ quit? When? ________ bloody or tarry stools, pain or rectal itching, rectal bleeding. Last
rectal exam, Guiac and results
☐ Recreational drugs (kind _____, amt _____, duration_______)
☐ Married / Divorced / Single / Children # GU: denies frequency, urgency, burning, dysuria, hematuria,
☐ Retired / Career ______________ nocturia, incontinence, change in color or odor, dribbling, retention,
oliguria. ADL: Urinary pattern, urology consult, date of exam and
Meds/OTC/Herbals: provider

☐ Male Genital: Weak urine stream, discharge from penis, lesions,

testicular pain or swelling, lumps on testicles, sexual dysfunction, STD’s.
ADL: TSE, use of condoms, sexuality

Allergies/Reactions: NKDA ☐ Female Genital: Menstrual history, (age of onset, frequency of

menses, duration of menses), LMP, menorrhagia, metrorrhagia, post-
FMH: mother/father/siblings/grandparents/children menopausal bleeding, amenorrhea, dysmenorrhea, vaginal discharge,
lesions on vulva, vulva pruritus, pregnancies, (Gravida-Para-Abortions-
M Live births), dyspareunia, STD’s
F Age of menarche: _____ ☐Number of pregnancies: G
Review of Systems: Flow/Frequency of menses: ______ ☐Number of Term >20wks: T
Duration of menses: _______ ☐Number of Preterm <20 wks: P
General: denies fatigue, loss/increase appetite, weight change, Exposure to DES: ☐ ☐Number of abortions/miscarriages: A
weakness, fever, chills, night sweats Complications of pregnancies: ☐ ☐Number of Living: L

Head: denies lumps, asymmetry, syncope, headache, dizziness, ADL: Last GYN exam, date and result of last pap smear, birth control
vertigo, recent trauma
Vascular: denies edema, phlebitis, calf pain, intermittent
Eyes: denies pain, redness, itching, burning, discharge, swelling, claudication, varicose veins, emboli
excessive tearing, blurring of vision, diplopia, spots, photophobia,
changes in vision or visual fields, glasses/corrective lenses/contact Musculoskeletal: denies pains in joints, swelling, heat, redness,
lens, date of last eye exam and name of provide stiffness, muscle weakness, muscle aching or pain, back pain or injury,
limitation in movement, ROM

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Neuro: denies fainting, dizziness, seizures, numbness, tingling, Breast: Size, symmetry, shape (protrusions, retractions), discharge,
parasthesias, weakness, speech disorders, tremors, headaches, head consistency, tenderness, nodules (location, size, shape, consistency,
injuries, imbalance, loss of balance or coordination, mood or mobility, tenderness), axillary lymph nodes
temperament changes, memory changes, loss of consciousness
Respiratory: easy, unlabored, clear bilat; ausculate posterior, tactile
Endocrine: denies temperature intolerance or sensitivity to heat or fremitus, percuss dullness/hyperresonance, Auscultate decreased
cold, polyuria, polydipsia, polyphagia, glycosuria, weight changes, sounds, added sounds: crackles, wheezes, rhonchi, bronchophony,
voice changes, change in glove or shoe size, fatigue egophony, pectoriloquy

Hematology: denies bleeding tendencies, bruising, lymph node Cardiovascular: RRR, normal S1 S2, no murmurs/rubs/gallops, grade
enlargement, blood type, history of transfusions ___/6 murmur (timing, shape, location, pitch: snap, rub, click), radiates
to carotid
Psychology: denies suicidal ideation, depression, history of mental
illness, anxiety, depression GI: +BS, soft, non-tender, auscultate sounds, murmurs, rubs, percuss
tympany/dullness, organomegaly, ascites, palp guarding, tenderness
Physical Exam: rebound, hernias

Vitals: BP: HR: RR: SaO2: T: Vascular: no ____ R/L pitting edema
HT: WT: BMI:
Pulses:
General: AAOx3, mood ______, adult, gender ______, in no acute DP PT POP FEM RADIAL
distress, ☐ nutritional status, ☐ personal hygiene, ☐ posture, Right
☐ anxiety, ☐ appears stated age Left

Skin: ☐ texture, color, temperature, turgor, any lesions Genital/Rectum: ☐ N/A ☐ deferred
☐ Note hair distribution, amount, hair texture
☐ Note color of nail beds and shape of nails Musculoskeletal: muscles, joints, symmetry, swelling, DTR, ROM,
tenderness, pain/pressure
Head: Note size, shape, symmetry, unusual lesions
Neuro: vibration, touch, pain, temp, strength, rapid-alternative
Eye: Position and alignment, eyebrow, eyelidslacrimal glands, cornea, movements,
sclera (jaundice), conjunctiva (color, injection), cornea, pupils
☐ Test visual fields, pupillary reaction  PERRLA (pupils equal, EKG: Date: Interpretation:
round, reactive to light and accommodation), EOMI (extra ocular
movements intact), nystagmus Labs: Date:
☐ Fundoscopic exam: cataracts, red reflex, optic disc, vessels:
papilledema, hemorrhages, retinopathy WBC Hgb Plt

☐ Snellen chart Hct

Ears: Inspect auricles, canals, TM Date/Diagnostics/Results

☐ Auditory acuity (whispering, clapping)
☐ Weber (forehead, equidistant, which ear is the sound louder? Na Cl Bun Glu
Lateralization to left or right?) unilateral conductive loudest in affective K HCO3 Cr GFR ASA:
ear Mallampati:
☐ Rinne (normal AC > BC +Rinne, conductive AC < BC –Rinne, CHADS2:
sensorineural AC > BC +Rinne )
PT INR
Nose/Sinuses: Inspect normal nose, septum, nasal mucosa. Ca Mg

Pain/pressure frontal/maxillary sinuses Phos PTT

Mouth/Throat: Jaw motion, lips, salivary glands, cheeks, tongue, teeth,

Impression:
gums, oral mucosa, pharynx, soft/hard palate, tonsils
Assessment Plan w/ Rationale
Neck/Nodes: ☐ neck, supple, no masses, trachea midline, no 1.
carotid bruits
2.
☐ Note size, consistency, mobility, tenderness: preauricular,
3.
postauricular, occipital, tonsillar, submandibular, submental, superficial
anterior cervical, supraclavicular, deep cervical 4.
☐ Thyroid gland: visible, symmetrical. Note size, symmetry, position of 5.
lobes, presence of nodules. Usually unpalpable. No goiter/nodules

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