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PATIENT IDENTIFICATION:Name Age Gender Occupation

CHIEF COMPLAINT :

HISTORY OF PRESENT ILLNESS:Symptom Onset date Acute/Gradual

Characterization of symptoms:Type /

LocationQuality Intensity (1-10) Onset /

Duration / Frequency

Setting Alleviating Factors

Aggravating Factors

Associated Sx

Course of symptoms from onset to present:

Current Status as compared to onset:

Relationship / Precipitating Factors – time of day, meals, activities:

Prior episodes?

Appropriate system-related ROS :

REVIEW HPI to assure understandingIs there anything else you would like to tell me?

PAST MEDICAL HISTORY:General:

OBSTETRIC HX :Type Date Result

MEDICAL HX: Hospitalizations and major medical illnesses:Diagnosis Date Therapy Hospitalization Result

MEDICATIONS: Name Dosage & Frequency Since when Side Effects

ALLERGIES: Allergen Reaction

Infectious diseases: Childhood (mumps / measles / chicken pox?)Rheumatic fever, pneumonia, TB?

Immunizations:

Health maintenance: PAP mammogram fecal occult blood

Accidents:

PERSONAL/ SOCIAL HX:Occupation: stressors, environmental exposure?

Recent travel:

HABITS:Smoking Alcohol use Drug Use

Dietary -- intake, snacks, restrictions:Caffeinated beverages? Exercise?

FAMILY HISTORY: (age, current health, major illnesses and cause of death)Father: Mother: Grandparents: Siblings:

Family hx of:HPI organ? Heart dx? HTN? Lipid disorder? CA? DIABETES? Arthritis? Kidney? Lung? GI? Allergic dx (asthma, hives)?

Endocrine(goiter)? Obesity? CVA? CNS/PNS (seizure, paralysis)? Osteoporosis? Psychiatric?

SEXUAL HISTORY:Sexually active? Men, women, or both? Having any concerns?Frequency/type/satisfaction of intercourse:

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REVIEW OF SYSTEMS (relate to HPI when possible):GENERAL – weight change; fever, chills, sweats; appetite change; fatigue

SKIN – rash, sweating, hair growth/loss, itching, easy bruising, petechiae, photosensitivity, nail changes, difficult healing

HEAD / NECK – headaches, trauma, dizziness, swollen LNs or glandsEYES – glasses, visual changes; inflammation, discharge, dry eyes, pain, photophobia

EARS – hearing loss, pain, tinnitus, dizziness/vertigo; ear inf., drainageNOSE – discharge, nosebleeds, nasal sores; obstruction, sinusitis

MOUTH/ THROAT– dentition, bleeding gums, oral ulcers, pain; dry mouth; swallowing probs, hoarseness, sore throat

RESP – dyspnea on exertion; cough, sputum, hemoptysis; asthma or wheezing; cyanosis

CV– chest pain, palpitations, SOB, syncope, edema, orthopnea, PND, exercise tolerance, fatigue, circulatory probs, claudication

hx of MI / CHF / murmurs, HTN, high cholesterol

GI – dysphagia, odynophagia, nausea, vomiting; dyspepsia, reflux or heartburn, loss of appetite, food intolerance,

abdominal pain; hematemesis; hematochezia, melena, jaundice, change in bowel habits, diarrhea, constipation

GU – urinary frequency, urgency, dysuria, hematuria, pyuria, previous UTI’s; discharge, nocturia, incontinence; unusual smell;

h/o proteinuria or kidney problems; renal stones

MENSTRUAL – menarche; last period, length of cycle, duration of flow, how regular, how heavy; pain with menstruation or intercourse;

vaginal bleeding or discharge, intermenstrual bleeding; last PAP, pelvic, and mammography; age of menopause

ENDOCRINE – endocrine probs; heat/cold intolerance; polyuria, polydipsia, polyphagia; h/o fractures/ osteoporosis;

MUSCULOSKELETAL – joint pain stiffness or swelling; neck or low back pain; muscular weakness or pain

NEUROLOGICAL – cognitive or memory changes; fainting, unconsciousness; numbness, tingling; strength/ weakness; coordination/gait; seizures

PSYCH – mood, sleep, depression, anxiety

PHYSICAL EXAMINATION:

VITAL SIGNS: T_____ P_____ R____ BP______/____

Wt. _____________ Ht. ________________

General Appearance & Mental status______________________________________

Skin: Inspect skin/nails _______________________________________________

HEENT: Hair & Scalp________________________________________________

Eyes: VISUAL FIELDS to confrontation __________________________________

EOMs ______________________ Pupil size, reactivity to light ________________

Ophthal exam and red reflex ____________________________________

Ears: TM’s (otoscope)____________________Test hearing _________________

Oropharynx: mouth, teeth, tongue, palatal elevation, gag reflex ________________

Face: observe for symmetry, CN V/ VII ___________________________________

Lymph nodes: _____________________________________________________

Palpate CAROTID pulses _____________________________________________

Auscultate for BRUITS _______________________________________________

Inspect and palpate THYROID gland (with swallow) ________________________

___________________________________________________________________

Insect Jugular Venous Pulse____________________________________________

Observe for shoulder symmetry_________________________________________

LUNG: Auscultate ________________________________________________

___________________________________________________________________

PERCUSS ________________________________________________

CV: Auscultate @ 4 areas w/diaphragm: listen for rate & rhythm,

murmurs, rubs, clicks, gallops __________________________________________

___________________________________________________________________

Check for aortic insufficiency (LSB with pt forward in exhalation)_____________

Pt. LYING DOWN:CV: Auscultation @ BASE and LSB ______________________________________

LL DECUBITUS: auscultation with Diaphragm & Bell @ apex ________________

Recheck jugular venous pulse___________________________________________

ABDOMEN: Auscultate for bowel sounds and bruits ________________________

Palpate 4 quadrants (assessing liver, spleen, and for masses) ___________________

___________________________________________________________________

Percuss for liver span _________________________________________________

PULSES: dorsalis pedis ______________ posterior tibial ___________________

Check for femoral bruits if distal pulse is diminished ________________________

Check distal perfusion and for edema ____________________________________

Lower extremity Musculoskeletal exam: feet to hips _________________

___________________________________________________________________

Pt. SITTING: Neuro exam: _____________________________________________

CNs _______________________________________________________________

Upper extremity Musculoskeletal exam: arms, shoulders, neck_________________

Sensation: touch, pin, position, vibration - lower extremities___________________

REFLEXES - plantar_____________ patellar_____________ biceps______________

Cerebellar coordination: finger-to-nose_____________________________________

Pt . STANDING

SPINE: (screening musculoskeletal. exam)________________________________

GAIT and station : heel / toe walking and tandem gait _______________________

Upper extremity drift/Romberg ___________________________________