DEMOGRAPHICS
Patient Initials:
Age:
Sex:
Race/Ethnicity:
SUBJECTIVE
CHIEF COMPLAINT (CC):
HISTORY OF PRESENT ILLNESS (HPI):
PAST HISTORY
PMH:
PSH:
PSYCHIATRIC HISTORY:
FAMILY HISTORY / SOCIAL HISTORY
FAMILY HISTORY (FH):
SOCIAL HISTORY:
MEDICATION RECONCILLIATION / REVIEW
MEDICATIONS & INDICATIONS:
(Prescribed & OTC)
ALLERGIES / IMMUNIZATIONS
ALLERGIES:
IMMUNIZATIONS:
HEALTH PROMOTION / HEALTH MAINTENANCE
NUTRITION / DIET:
EXERCISE REGIMEN:
TOBACCO/ALCOHOL/
ILLICIT DRUG USE:
SAFETY MEASURES:
SCREENINGS / EXAMS:
REVIEW OF SYSTEMS
CONSTITUTIONAL / GENERAL:
EYES:
EARS/NOSE/MOUTH/THROAT:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL/ABDOMEN:
GENITOURINARY:
MUSCULOSKELETAL:
INTEGUMENTARY:
NEUROLOGICAL:
PSYCHIATRIC:
ENDOCRINE:
HEMATOLOGIC / LYMPHATIC:
ALLERGIC / IMMUNOLOGIC:
OBJECTIVE
VITAL SIGNS:
T:
HR:
BP:
mm/Hg
RR:
O2:
Height:
Weight:
BMI:
PHYSICAL EXAM
CONSTITUTIONAL / GENERAL:
EYES:
EARS/NOSE/MOUTH/THROAT:
NECK:
RESPIRATORY:
CARDIOVASCULAR:
CHEST / THORAX (BREASTS):
GASTROINESTINAL / ABDOMEN:
GENITOURINARY:
LYMPHATIC:
MUSCULOSKELETAL:
INTEGUMENTARY / SKIN:
NEUROLOGIC:
PSYCHIATRIC:
RESULTS REVIEW
ASSESSMENT
DIAGNOSIS (Dx)
DIFFERENTIAL DIAGNOSES
PLAN
DIAGNOSTIC WORKUP
PHARMACOLOGICAL TREATMENTS:
NON-PHARMACOLOGICAL TREATMENTS:
REFERRALS:
EDUCATION:
Follow-up
What would you do differently: