Patient Name:

DOB:

Emergency contact:

Room#:
Gender:

Age:

Patient History

Chief Complaint:
Source (person/reliability):
HPI:
Location (radiate/referred):
Quality:
quantity (scale,affect on life):
timing (start,freq,better/worse):
setting (when/where):
affecting factors:
assoc manifestations (fever,chills,nausea,vomit,wt):
personal concerns (what does pt think):
PMH:
Recent/chronic illnesses:
Trauma/Hospitalizations/surgeries:
Immunizations:
Cancer / STD Screening:
Diabetes/Hypertension/CAD/Chol/Asthma/Arthritis/HIV/Infections:
Family History(age/health/c.o.d/):
DM___HTN___CAD___HypChol___Asthma___Arthritis/Gout___Cancer

Medications:
Allergies:
OB/GYN (Preg/term/abortion/contracep/menstrual cycles):

Social HX:
Occupation:
Married?___ Family:
Support system:
Spirituality/religion:
Diet:
Sleep:
Stress:
Smoking/Drugs/EtOH (last use):
Travel:
Sexual history:

Date:
Race:

Code:

Review of Systems
1. General
____Poor state of health
____Fever
____Chills
____Change in weight
____Weakness
____Fatigue
____Sweats
____Hot/Cold intolerance
____History of anemia
____Bleeding tendencies
____Blood transfusions
____Exposure to
radiation
____Violent relationships

____Sinus infections
____Hay fever
6. Mouth and Throat
____Condition of teeth
____Last dental visit
____Condition of gums
____Bleeding gums
____Frequent sore
throat
____Burning of tongue
____Hoarseness
____Voice changes
____Postnasal drip

2. Head
____"Dizziness"
____Headaches
____Pain
____Fainting
____History of injury
____Stroke

7. Neck
____Lumps
____Goiter
____Pain on movement
____Tenderness
____Hx of "swollen
glands"
____Thyroid trouble

3. Eyes
____Use of eyeglasses
____Change in vision
____Double vision
____Excessive tearing
____Pain
____Recent exam
____Pain looking at light
____Redness
____Discharge
____Infections
____History of glaucoma
____Cataracts
____Injuries

8. Chest
____Cough
____Pain
____Shortness of breath
____Sputum production
____Tuberculosis
____Asthma
____Pleurisy
____Bronchitis
____Coughing up blood
____Wheezing
____Last X-ray
____Last test for TB
____History of BCG

4. Ears
____Hearing impairment
____Use of hearing aid
____Discharge
____"Dizziness"
____Pain
____Ringing in ears
____Infections

9. Cardiac
____Pain
____High blood pressure
____Palpitations
____Shortness breath w/
exertion
____ when lying flat
____...while sleeping
____History of heart
attack
____Rheumatic fever
____Heart murmur
____Last ECG
____Other tests for heart

5. Nose
____Nosebleeds
____Infections
____Discharge
____Frequency of colds
____Nasal obstruction
____History of injury

10. Vascular
____Pain while walking

____Swelling of legs
____Varicose veins
____Thrombophlebitis
____Coolness of
extremity
____Loss of hair on legs
____extremity
discoloration
____Ulcers
11. Breasts
____Lumps
____Discharge
____Pain
____Tenderness
____Self-examination
12. Gastrointestinal
____Appetite
____Excessive hunger
____Excessive thirst
____Nausea
____ Swallowing
____Constipation
____Diarrhea
____Heartburn
____Vomiting
____Abdominal pain
____Change in stool
color
____in stool caliber
____in stool consistency
____in freq. bowel mvmt
____Vomiting up blood
____Rectal bleeding
____Black, tarry stools
____Laxative/antacid
____Excessive belching
____Food intolerance
____ab size change
____Hemorrhoids
____Infections
____Jaundice
____Rectal pain
____Previous ab X-rays
____Hepatitis
____Liver disease
____Gall bladder
13. Urinary
____Frequency
____Urgency
____Prob. Starting
____Incontinence
____Excessive urination
____Pain on urination

____Burning
____Blood in urine
____Infections
____Stones
____Bed wetting
____Flank pain
____waking to pee at
night
____History of retention
____Urine color
____Urine odor
14. Male genetalia
____Lesions on penis
____Discharge
____Impotence
____Pain
____Scrotal masses
____Hernias
____Ability to enjoy sex
____Fertility problems
____Prostate problems
____Hx of venereal dz
15. Female Genitalia
____Lesions on labia
____Itching
____Discharge
____Last Pap
smear/result
____Pain on intercourse
____Birth control
methods
____Ability to enjoy sex
____Fertility problems
____Hernias
____Hx. of venereal dz.
____Hx of DES
exposure
____Age at menarche
____Interval bw periods
____Duration of periods
____Amount of flow
____Date of last period
____Bleeding bw periods
____# pregnancies
____Abortions
____Term deliveries
____pregnancy
complications
____Descriptions of
labor
____# of living children
____Menstrual pain
____Age at menopause

____Menopause
symptoms
____Postmenopausal
bleed
16. Skin
____Rashes
____Itching
____Hives
____Easy bruisability
____History of eczema
____Dryness
____Changes in skin
color
____in hair texture
____in nail texture
____Hx of skin disorders
____Lumps
____Use of hair dyes
17. Musculoskeletal
____Weakness
____Paralysis
____Muscle stiffness
____movement limitation
____Joint pain
____Joint stiffness
____Arthritis
____Gout
____Back problems
____Muscle cramps
____Deformities
18. Neurologic
____Fainting
____"Dizziness"
____"Blackouts"
____Paralysis
____Strokes
____"Numbness"
____Tingling
____Burning
____Tremors
____Loss of Memory
____Psychiatric
Disorders
____Mood Disorders
____Nervousness
____Speech Disorders
____Unsteady Gait
____behavior changes
____Loss of
consciousness
____Hallucinations
____Disorientation

Physical Exam
Supine BP_____ Pulse_____
Sitting BP_____ Pulse_____
General:
Pallor:
icterus:

HEENT

RR_____
WNWD:

Head Normocephalic/atruma=c: __________

Hair:
Face:
Symmetry:
Skull / Scalp:
Eyes (red? icterus?: __________________)
Position and Alignment:
Extraocular Structures:
brows:
lacrimal apparatus:
lids:
lashes:
Conjunctiva and Sclera:
Corneas and Lenses:
Iris:
Visual acuity and Visual Fields:
Pupils (II,III) (PERRLA):
size (equal):
direct and consensual reaction:
accommodation:
Extraocular muscles (III,IV,VI):
eye movement (EOMI):
nystagmus:
Fundus:
retina:
optic disc:
vessels:
macula:

CARDIOVASCULAR

Temp_____ Wt_____ Ht_____

Skin: Discolora=on: __________________
Rashes:
Erythema:
Edema:
Tats: _____________________________
Jaundice: _________________________
Ears
Pinnae:
Mastoid Percussion: Canal:
Tympanic Membrane:
Hearing (VIII): intact bilaterally?_________
Weber:
Rinne:
L:
R:

Nose Discharge? __________________

Mucosa:
Septum:
Turbinates:
Sinuses (palpation, transillumination):

Mouth / Throat Cant speak?: _____________

Lips:
Mucosa:
Teeth:
Gums:
Tongue (deviation, appearance, VIII):
Palates / Uvula:
Tonsils:
Pharynx (X):
Intubated? _______________
Discharge? __________________

NECK
Inspection:
trachea (midline, deviation):
masses:
JVD:
Palpation:
Glands:
parotid:
submandibular:
thyroid:
Caro=d bruit present:

LUNGS

Wounds/scars:________________

Inspection:
breathing pattern (rate, rhythm, depth, effort):

Lymph nodes:
1. pre-auricular:

6. submental:

2. posterior auricular:

7. superficial cervical:

3. occipital:

8. posterior cervical chain:

4. tonsillar:

9. deep cervical chain:

5. submaxillary:

10. supraclavicular:
(Virchows)

Percussion:
consolidation (dullness):
level of diaphragm:
abnormal movements (retraction, asymmetry, accessory
diaphragmatic excursion:
muscle use, paradoxical inspiration):
Auscultation:
shape (barrel, pectus carinatum or excavatum):
breath sounds (pitch, intensity, duration): rales,
wheezes, rubs:
Palpation:
egophany (e a):
whispered pectoriliquoy (sixty-six):
tenderness:
fremitus (toy boat):
Repeat for Anterior Chest:

pulse: weak/nml? __________________________

Inspection and Palpation:

chest (scars):
JVP and venous pulse:
peripheral pulses (R/L lag, regularity, strength,
contour):
1. carotid:
5. popliteal:
2. brachial:
6. posterior tibialis:
3. radial:
7. dorsalis pedis:
4. femoral:
PMI (location, diameter, amplitude, duration):

ABDOMEN

Auscultation (supine, sitting, left lateral decubitus):

rate:
rhythm:
S1:
S3:
S2:
S4:
extra sounds (timing, shape, location, radiation, intensity):
carotid (bruit present):

Ascites? _______________

Inspection:
skin (scars, striae, dilated veins):
umbilicus:
contour:
symmetry:
enlarged organs or masses:
peristalsis or pulsations:
Auscultation:
bowel sounds:
bruits:
friction rubs:

MUSCULOSKELETAL

Percussion:
gas distribution:
air-fluid level, shifting dullness, fluid wave:
liver span (nl: 6-12 cm):
splenomegaly:

Palpation (sore points last):

areas of tenderness (NTND):
rigidity:
masses:
peritonitis:
abdominal aorta:
rebound tenderness:
liver span:
CVA tender? _____________________

Inspection and Palpation: LE edema? ___________________

range of motion: nml/decd?__________________
inflammation (erythema, swelling, warmth, tenderness):
crepitus:
deformity (bone or soft tissue):
surrounding tissues (atrophy or skin changes):
strength: UE/LE _____________________________
symmetry of movement:
muscle atrophy: _____________________________

NEUROLOGICAL
Cranial nerves:
I: smell soap:
V: sens: face; motor: mastication muscles:
VII: facial expressions:
IX/X: gag:
XI: head turn, shoulder shrug:
Motor:
Strength, Tone (0-5, nerve function):
shoulders:
fingers:
arms:
hips:
wrists:
knees:
grip:
ankles (clonus):
Cerebellar:
rapid alternating movements:
(dysdiadochokinesis)

point-to-point test (dysmetria):

Rhomberg test:
gait:
(tandem walk, heel-toe, hop in place, rise from sit)

spleen:
Rovsings sign:
psoas sign:
obturator sign:
Murphys sign

Function:
gait:
spine curvature:
Drawer sign:
Phalens test:
Tinel's sign:

Sensory:
light touch (cotton):
vibration (128hz):
pain (sharp/dull):
temp (if pain abnl):
position (toes/fingers):
2-pt discrimination:
stereognosis:
graphesthesia:
Reflexes (0-4+):
biceps (C5-6):
quadriceps (L3-4):
triceps (C7-8):
Achilles (S1-2):
brachioradialis (C5-6):
Primitive reflexes:
Babinski:
snout sign:
grasp sign:
glabellar sign:
suck sign:
Mini-Mental Status Exam ( = 30):
orientation (time/location = 10):
registration (identify 3 objects = 3):
attention and calculation (serial 7s = 5):
recall (3 objects = 3):
language (name, repeat, follow, read, write, draw = 9):
mood/aect: ____________________