or HISTory AnD PHySICAl ExAm by luk10459

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									UNIV ERSIT Y OF VIRGINIA HEALTH SYSTEM                                                                          PLaCe LaBeL HeRe.




                  0300001
                                                                                                  iF LaBeL NOt aVaiLaBLe, WRite iN Pt Name & mR#


or HISTory AnD PHySICAl ExAm
Date: _____________________________________________           time: _________________________________________________
Referring mD: ______________________________________          PCP: _________________________________________________
address: __________________________________________           address: ______________________________________________
___________________________________________________            ______________________________________________________
Phone# ___________________________________________            Phone# _______________________________________________

History: Previous H & P done on what date ____________
Chief Complaint:


History of Present illness:


Past medical History:


     allergies:


List all current medications on the Patient Pre-Admission Medication List. Form # 080361 Attached

Past Surgical History:


Pertinent Family/Social History:

Review of systems: Blank indicated NO complaint ---- otherwise describe complaint
eyes:_______________________________         Skin:________________________________ eNt/mouth: __________________________
Neurologic:__________________________        Cardiac:_____________________________ Psychiatric: __________________________
Respiratory:_________________________        Gastrointestinal: ______________________ Heme/Lymphatic: _____________________
Genitourinary:_______________________        endocrine:___________________________ allergic/immunologic:__________________
musculoskeletal:______________________
Physical Exam         Ht________________ Wt_________________ P________________ BP________________ RR_______________
General: ___________________________________________          Neck: _________________________________________________
Respiratory/Chest: __________________________________         Cardiac: _______________________________________________
abdomen: _________________________________________            extremities: ____________________________________________
Assessment:                                                   Plan:




Signature: _________________________________________ PIC: _______________ Date: ________________ Time: ____________
                           HeaLtHCaRe PROFeSSiONaL

Attending Comments __________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________

Attending Signature: _______________________________ PIC: _______________ Date: ________________ Time: ____________

FORm # 030325       Cat: 03 - H&P             (ReV. 05/08)      to reorder, log onto http://www.virginia.edu/uvaprint                         1 OF 2
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