CHIEF COMPLAINT (CC):
HISTORY OF PRESENT ILLNESS (HPI): (must be in paragraph form)
MEDICATIONS: (name, strength, dose, frequency, indication of use, if any who prescribed it)
ALLERGIES:
SOCIAL HX: (must be in paragraph form)
SEXUAL HISTORY:
MEDICAL HX (PMH):
Childhood:
Surgical:
Ob/Gyn:
Psychiatric:
VACCINATIONS: (list of all vaccines with dates administered)
FAM HX: (specify family member affected/age at death, diagnosis):
Mother:
Father:
Paternal Grand Mother:
Paternal Grand Father:
Maternal Grand Mother:
Maternal Grand Father:
Review of Symptoms (ROS):
HEENT:
Neck:
Cardiovascular:
Respiratory:
Gastrointestinal System:
Urinary System:
Musculoskeletal System:
Neurologic System:
Psychiatric:
Endocrine:
Integumentary System:
PHYSICAL EXAMINATION
Appearance:
Vital Signs: BP: HR: RR: Temp:
Skin:
HEENT:
Neck:
Heart:
Chest and Lungs:
Peripheral Vascular System and Lymphatic System:
Abdomen:
Musculoskeletal:
Neurological Exam:
IMPRESSION/PLAN (Include differential diagnosis for each problem):
Primary Diagnosis: (Paragraph form, site references)
Differential Diagnosis: (Paragraph form, site references)
PLAN: (include office visits, blood tests, xrays, EKGs, CT scans, MRIs, reasons why you are ordering the test, and citations)
Diagnostic Tests:
Pharmacologic Treatment:
Prevention:
Treatment Plan:
General Intervention
Patient Teaching
Dietary Managment
References