GENERAL EXAM FORM
Revised 04/22/05, 06/15/07
Date __________________________
Name: _____________________________________ Age: ______ Sex:_______ Smokes________ PPD______
Allergy: ____________________________________Alcohol _____________Illicit Drugs_________________
Meds:  Changed since last visit
 No change since last visit
B/P_____/______ P______ Regular  Irregular RR______  Labored  Non-Labored Temp ______
Weight_________ Height _______
Last Pap___________ Hyst _________ Tubal ________________
HgbA1c __________
Blood Sugar ____________  Fasting /  Random
Microalbumin ________
BMI _________ Last Retinal Eye Exam _______________ Last Testicular Exam _________________
Chief Complaint/HPI: Pain Scale:___________ Peak Flow __________ (avg. of 3) Pulse Ox ____________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
_______________________________________________Signature of Screening Nurse______________________________
Review of Systems
Legend ( О = Positive Finding
/ = Negative Finding
Blank = Not asked)
Constitutional: fever, chills, fatigue, wt change____#, night
MS: bone pain rating_____(1-10 scale), location _________,
sweats
duration________, radiates _________, quality (sharp, achy,
HEENT: visual changes, hearing loss, rhinorrhea, sore throat,
dull, throbbing), intermittent/ constant, myalgias/arthralgia
oral ulcers/lesions, dry mouth, postnasal drip, dry eyes,
(edema, warmth, erythema) __________, joint__________
allergies (seasonal, ______________)
Renal: hematuria, dysuria, increased freq, nocturia, hesitancy,
GI: nausea, vomiting, diarrhea ____BM’s/day, watery, bloody,
groin pain (colicky), flank pain
mucous, melena, BRBPR, constipation, abd pain rating_____
Neuro: paresthesias, imbalance, hand/foot numbness, shooting
(1-10 scale), ____quad, sharp, dull, throbbing, crampy,
pains ____(1-10 scale), diploplia, dysarthria, hearing loss,
_________ radiates _________________worse with
dysphagia, anosomnia, amarosis fugax, headache ______(1-10
_____________ positional ____________________
scale), dull, sharp, shooting, constant, intermittent, occipital,
Pulmonary: dyspnea (rest/exertion), orthopnea, PND, LE
temporal, parietal, frontal, neck, behind eye, duration
edema, cough (dry, sputum ____), worse at night, snoring
_____________, aggravating/alleviating factors
Cardiovascular: chest pain rating ____(1-10 scale),
________________, wake you in the middle of the night;
location________, duration_____, radiates _________ sharp,
Yes/No. HA associated with; scotomas, tongue biting, nausea,
dull, achy, heavy, tight, started suddenly, over hours, over days.
postictal, incontinence, witnessed. _________________
positional; worse with climbing stairs, walking, rest, breathing
weakness location _____________ duration _______
deeply, lying flat, better with ____________
GU/GYN: dyspareunia, discharge, lesions, nodules, H/O STD
Endocrine: polyphagia, polydypsia, polyuria, dry skin, brittle
___________, incontinence, urine/stool (sneeze, laugh, urge,
hair, tremors, heat/cold intolerance, depression, irritability,
leakiness, hesitancy, dribbling, erectile dysfunction, am
hand numbness, nipple discharge (milky, bloody, clear)
tumescence, LMP________ duration ______ regular/irregular
Hematology: bleeding, easy bruising, petechiae, freq
Psychiatric: depression, anxiety, SI, HI, insomnia, change in
infections, hemearthosis, lymphadenopathy
appetite, difficulty concentrating, anhedonia, grandiose
Dermatology: rash, pruritic, moles (changed in color, size),
delusions, hallucinations, visual/verbal
acne ______________________
ADL’S ___________________________________________
Sexual History: ____________________________________
History:
Changes in history:
Past Medical history reviewed and updated with patient
_________________________________________________
Past family history reviewed and updated with patient
_________________________________________________
Past social history reviewed and updated with patient
_________________________________________________
Physical Exam
General:
CV:
HEENT:
GI:
Derm:
GU/GYN:
Neck:
Rectal:
Pulmonary:
Neuro:
Breast:
Extremity:
Lymph:
MS:
Signature of Provider ___________________________________________
Process: To be used on initial (non-acute) visit and at discretion of provider for other visits. Filed in chart under progress note in
chronological order, with newest on top.
GENERAL EXAM FORM
Name: _______________________________________
Assessment:
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
Plan:
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
_____________________________________________
Labs Ordered:
_________________________SMMC Voucher / Order
_________________________SMMC Voucher / Order
_________________________SMMC Voucher / Order
_________________________SMMC Voucher / Order
_________________________SMMC Voucher / Order
Diagnostics Ordered:
____________________________DH Voucher / Order
____________________________DH Voucher / Order
____________________________DH Voucher / Order
____________________________DH Voucher / Order
____________________________DH Voucher / Order
Medication changes:
____________________________________PAP /
____________________________________PAP /
____________________________________PAP /
____________________________________PAP /
____________________________________PAP /
____________________________________PAP /
____________________________________PAP /
____________________________________PAP /
____________________________________PAP /
____________________________________PAP /
____________________________________PAP /
Discontinued Medications:
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
Rx
Rx
Rx
Rx
Rx
Rx
Rx
Rx
Rx
Rx
Rx
Revised 04/22/05, 06/15/07
Date: ________________________
Referral given to:
______________________________________________
______________________________________________
______________________________________________
______________________________________________
Referral to Social Service: _______________________
PAP: _________________________________________
Dietician: _____________________________________
Educator:_____________________________________
 Stressed importance of keeping referrals/appts
Other Instructions:
Diet Type:
Low Cholesterol
Low Salt
 2000mg Sodium Diet
1200 Cal ADA
 ________Cal ADA
 Other ___________
Activity Changes:
 Walk 30 min daily
 Walk as tolerated
 Continue current routine
 Other ______________________________________
Monitoring: 1 2 3 4 _________ times daily
 blood sugars fasting (goal 80-120)
 before meals (goal less than 120)
 2 hrs after a meal (goal less than 140)
 Mail or bring in to office after 2 weeks
Self Management Goals:
 Stop Smoking
 Wt loss of _________ pounds per week
 Other ______________________________________
Patient Response to Teaching and Discharge Instructions
listed on this form.
 Verbalized Understanding
 Repeats Instructions
 Other Comments_____________________________
_____________________________________________
Signature of Discharge
Nurse_____________________________________
Discharge Instruction:
Return for:  FU
Annual HP
 Pap
 Procedure ____________ Other __________
In ______Days_____Weeks_____Months _____Year
Refill Routine Meds for:
 1 mo  3 mo  4 mo  6 mo  1yr
 Other _______________
Signature of Provider ___________________________________________
Process: To be used on initial (non-acute) visit and at discretion of provider for other visits. Filed in chart under progress note in chronological order, with
newest on top.