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					Name/ID:                                    Age:      DOB:    /   /       Sex: M /F     Race: W B H A
Admission date:   /   /
Chief Complaint: ___________________________________________________________________
___________________________________________________________________________________
History of Present Illness
Onset:________________________________________Symptoms:___________________________________________
Location:_____________________________________ Quality:______________________________________________
Quantity:______________________________________Timing:_____________________________________________
Setting:________________________________________Aggravation/Relief:___________________________________
Associated problems:________________________________________________________________________________
Notes______________________________________________________________________________
___________________________________________________________________________________
Past Medical History
Past Illnesses:_________________________________________________________________________
Childhood illnesses: ____________________________________________________________________
Hospitalizations: _______________________________________________________________________
Medical: ____________________________________________________________________________
Surgical: ____________________________________________________________________________
Medications/dosage:_____________________________________________________________________
_________________________________________________________________________________________________
Allergies: ___________________________________________________________________________
Immunizations:________________________________________________________________________
Cardiac risk factors: Dyslipidemia / HTN / DM /Central Obesity / Family Hx
Family History (ages, conditions, diseases- chronic, malignant, and hereditary, deaths)
Mother:________________________________________Father:_____________________________________________
Siblings:__________________________________________________________________________________________
Spouse/partner:_____________________________________________________________________________________
Children:__________________________________________________________________________________________
Relatives:_________________________________________________________________________________________
Social History
Tobacco (amount, duration):__________________________________________________________________________
Diet:_____________________________________________________________________________________________
Exercise:__________________________________________________________________________________________
Caffeine:__________________________________________________________________________________________
Alcohol:__________________________________________________________________________________________
Substance abuse:____________________________________________________________________________________
Education:_________________________________________________________________________________________
Occupation:________________________________________________________________________________________
Marital status: Single / Married / Divorced / Widow
Faith:_____________________________________________________________________________________________
Sexual History
Libido:_________________________________________Sex life:____________________________________________
STDs:__________________________________________Discharge:__________________________________________
Contraception:__________________________Last menstrual pd (duration, flow, regularity, req): __________________
Age at menarche:_______Age at menopause:________Pregs/births:_____/______Vaginal/C-
sections:______/_____Abortions:________




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                                                          Physical Exam
General appearance
Apparent state of health:______________________________Nutritional status: Slim / Cachectic / Obese / Nl
Apparent age:________ Signs of acute/chronic disease:_____________________________________________________
Gait:_________________________________Dress:_____________________Hygiene:___________________________
Cooperation:____________________________________Odor (alcohol, acetone, fecal, etc.):_______________________
Vitals
BP:_____/_____RR:_____HR:___________Temp:_______Weight:________Height:________
Skin
Color:_______________________Temp:______________Moisture:________________Edema:____________________
Pigmentation:__________________________________Hair:______________________Nails:_____________________
Lesions/scars/textures:_______________________________________________________________________________
Tattoos/pierce:______________
Lymph Nodes: pain/tenderness:
-Cervical- -submaxillary- -submental- -occipital- -preauricular- -post. auricular- -epitrochlear- -axillary-
Head (skull, scalp, face- shape, size, symmetry, swelling):__________________________________________________
Eyes (positions, lids, conjunctiva, sclera, corneas, irises):___________________________________________________
EOMs:________________________________________Pupils: -equal- -round- -reactive- -accomodation-
Acuity:____________________________________Visual fields:____________________________________________
Funduscopy (red reflex, optic disk, vessels): _____________________________________________________________
Ears: Inspection:________________________________Weber:________________________Rinne:________________
Acuity:________________________________________Otoscopy:___________________________________________
Nose (inspect, turbinates, sinuses, olfaction):_____________________________________________________________
Mouth (jaw motion, lips, mucosa, tongue, teeth, palates, tonsils):______________________________________________________
Neck (inspect, flexibility, trachea, thyroid):______________________________________________________________
Chest/Lungs (shape, resp mvts, expand/retract): P:_____________________________ A:_________________________
Tactile fremitus:                                    P:_____________________________A:_________________________
Percussion (dullness, resonance, dia. excursion): P:_____________________________ A:_________________________
Ausc (vesicular/symm or abn breath sounds):         P:_____________________________ A:_________________________
CV: Neck: JV palp:                                  Carotid pulse (palp, ausc):_____________________________________
    Heart (pulsation, PMI, percussion):__________________________________________________________________
    Sounds (rhythm, S1/S2, S3/S4 splitting):_____________________________________________________________
    A,P,T,M (timing, shape, location, pitch, snap, rub, click):________________________________________________
Abd: (skin, umbil., shape, size, symm, distention henias, scars):______________________________________________
Ausc (bowel sounds, bruits):__________________________________________________________________________
Perc (liver, spleen):__________________________________________________________________________________
Palp (tenderness, rebound, masses, h/s megaly, pulses):_____________________________________________________
Periph Vasculature
Skin color: ________________________________Edema:_____________________Varicose veins:________________
Pulses: Radial:_________Femoral:___________Popliteal:_____________Ptib:________________Dpedis:___________
MuscSkel (size, symm, swelling, impairments, deformities, skin, ROM, tender, consistency)
Muscles:__________________________________________________________________________________________
Joints:____________________________________________________________________________________________
Bones (+spinal curvature):____________________________________________________________________________
DTRs: Bicepts:____________Tricepts:____________Brachiorad:_____________Patella:__________Achilles:________
Bbinski:___________________
Mental Status: Orientation (person, place, time):_________________________________________________________
Mood:_________________________________________Attention:___________________________________________
Speech (clarity, rate, pitch, fluency, hoarse):__________________________Posture/expression:____________________
Memory (short/long):_____________________________Thought/perception:___________________________________
Cranial Nerves: 1O            2O      3O      4T         5T        6A     7F     8AT      9G     10V       11A     12H
Motor: (tremors, tics, muscle tone, strength, finger-to-nose coord, pronator drift):_______________________________
Sensory: (touch, pain, temp, vibration, Romberg propriocepton, graph/stereo):__________________________________

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                                                Review of Systems

General                                 Heart/Vascular                              Female genitalia
Fever__________________________         Chest pain or discomfort________________    Genital lesions_______________
Chills__________________________        Palpitation__________________________       Itching_____________________
Unusual sweats__________________        Dyspnea with exertion__________________     Discharge___________________
Weight loss or gain_______________      Orthopnea___________________________        Dyspareunia_________________
Weakness or fatigue______________       Paroxysmal nocturnal                        Age at menarche______________
Heat or cold intolerance___________     dyspnea_____________________________        Frequency of periods__________
                                        Syncope/near-syncope__________________      Duration of periods____________
Skin                                    Intermittent claudication________________   Amount of flow_______________
Rashes_________________________         Lower extremity edema_________________      Date of last period____________
Pruritus________________________                                                    Dysmenorrhea________________
Changes in skin color_____________      Breasts                                     Metrorrhagia_________________
Changes in hair or nails____________    Lumps or masses______________________       Number of pregnancies_________
Piercings_______________________        Discharge____________________________       Abortions___________________
Lumps or masses_________________        Pain________________________________        Term deliveries_______________
Bruising or bleeding______________      Self-examination______________________      Age at menopause_____________
                                                                                    Menopausal symptoms_________
HEENT                                   GI                                          Postmenopausal bleeding_______
Dizziness_______________________        Appetite_____________________________
Headaches______________________         Anorexia____________________________        Musculoskeletal
Eyeglasses/contacts_______________      Polydipsia___________________________       Muscle weakness_____________
Change in vision _________________      Dysphagia___________________________        Stiffness____________________
Blurry vision____________________       Odynophagia_________________________        Myalgias____________________
Visual loss______________________       Heartburn____________________________       Arthralgias__________________
Diplopia________________________        Nausea______________________________        Joint swelling________________
Eye pain________________________        Vomiting____________________________        Back pain___________________
Excessive tearing or                    Diarrhea_____________________________
discharge_______________________        Constipation_________________________       Neurologic
Photophobia____________________         Melena______________________________        Focal weakness or
Redness of eyes__________________       Hematochezia________________________        paralysis____________________
Scotomata______________________         Change in bowel habits_________________     Vertigo_____________________
Difficulty hearing________________      Abdominal pain_______________________       Seizures_____________________
Tinnitus________________________        Food intolerance______________________      Loss of sensation______________
Epistaxis_______________________                                                    Paresthesias__________________
Nasal congestion or rhinitis_________   Urinary                                     Tremor_____________________
Bleeding gums___________________        Frequency___________________________        Memory loss_________________
Sore throat______________________       Urgency_____________________________        Gait disturbance______________
Hoarseness _____________________        Dysuria_____________________________        Loss of coordination___________
Change in voice__________________       Nocturia_____________________________       Mood changes________________
                                        Incontinence_________________________       Nervousness_________________
Neck                                    Hematuria___________________________
Lumps or masses_________________        Flank pain___________________________
Stiff neck_______________________
                                        Male genitalia
Chest                                   Penile lesions_________________________
Cough_________________________          Discharge____________________________
Sputum________________________          Scrotal masses________________________
Hemoptysis_____________________
Pleurisy________________________
Dyspnea________________________
Wheezing______________________




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