Name:
DOB:
Gender:
Race :
Chief Complaint:
History of Present Illness:
Past Medical History:
□ CAD
□ CHF
□ MI
□ HTN
Vitals:
Blood Pressure:
Pulse:
Temperature:
O2:
Height:
Weight:
Allergies:
Medications:
□ COPD
□ Asthma
□ DM
□ CKD
□ Thyroid
□ Swelling
□ Redness
□ Pain
□ Sinus pressure
□ Sinus pain
□ Epistaxis
□ Polyphagia
□ Polyuria
Ears:
□ Pain
□ Discharge
□ Tinnitus
□ Hearing loss
Throat:
□ Pharyngitis
□ Voice change
Respiratory:
□ Cough
□ Dyspnea
□ Wheezing
□ Apnea
□ Choking
□ Chest tightness
Review of Systems:
Constitutional:
□ Appetite change
□ Activity change
□ Fatigue
□ Fever
□ Chills
□ Weight change
Eyes:
□ Visual disturbance
□ Photophobia
Nose:
□ Discharge
□ Congestion
Skin:
□ Rash
□ Wound
Cardio:
Endocrine:
□ Chest pain
□ Heat intolerance □ Leg swelling
□ Cold intolerance □ Palpitations
□ Polydipsia
Physical Exam (Note abnormal findings):
General/Psych:
Cardiovascular:
GU:
HEENT:
Musc:
Pulmonary:
GI:
□ Pain
□ Distention
□ Constipation
Diarrhea
□ Nausea
□ Vomiting
□ Rectal bleeding
□ Blood in stool
□ Frequency
□ Genital sore
□ Hematuria
□ Menstrual problem
□ Pelvic pain
□ Urgency
GU:
□ Vaginal pain
□ Difficulty urinating □ Vaginal discharge
□ Dyspareunia
□ Vaginal bleeding
□ Dysuria
□ Enuresis
Musculoskeletal:
□ Flank pain
□ Arthralgias
Assessment:
Skin:
Plan:
Neck:
Abdominal:
Neuro:
□ Back pain
□ Joint swelling
□ Myalgias
□ Neck pain
□ Syncope
□ Tremors
□ Weakness
Psych:
Neuro:
□ Agitation
□ Headaches
□ Behavior issues
□ Dizziness
□ Confusion
□ Light-headedness□ Depression
□ Numbness
□ Anxiousness
□ Seizures
□ Suicidal
□ Speech issues
□ Homicidal