Date and Time: Ears: denies pain, discharge, infections, tinnitus, changes in hearing, Neuro: denies fainting, dizziness,

ections, tinnitus, changes in hearing, Neuro: denies fainting, dizziness, seizures, numbness, tingling, Breast: Size, symmetry, shape (protrusions, retractions), discharge,
injury, hearing aid, audiometry; date and provider name parasthesias, weakness, speech disorders, tremors, headaches, head consistency, tenderness, nodules (location, size, shape, consistency,
ID: Age: ___ Gender: ___ Ethnicity: Insurance: injuries, imbalance, loss of balance or coordination, mood or mobility, tenderness), axillary lymph nodes
Nose: denies epistaxis, obstruction, airflow, discharge, frequent colds, temperament changes, memory changes, loss of consciousness
‫܆‬AD/Living Will ‫܆‬Copy olfactory changes, postnasal drip, sinus pain or infection. Respiratory: easy, unlabored, clear bilat; ausculate posterior, tactile
‫܆‬Health Proxy: _______________ (relationship) Endocrine: denies temperature intolerance or sensitivity to heat or fremitus, percuss dullness/hyperresonance, Auscultate decreased
Mouth/Throat: denies bleeding gums, sores in mouth, toothache, cold, polyuria, polydipsia, polyphagia, glycosuria, weight changes, sounds, added sounds: crackles, wheezes, rhonchi, bronchophony,
CC: “ changes in taste, dentures, sore throat, difficulty chewing or voice changes, change in glove or shoe size, fatigue egophony, pectoriloquy
swallowing, hoarseness, voice changes, date of last dental exam and
provider. ADL: Dental Hygiene. Hematology: denies bleeding tendencies, bruising, lymph node Cardiovascular: RRR, normal S1 S2, no murmurs/rubs/gallops, grade
HPI: enlargement, blood type, history of transfusions ___/6 murmur (timing, shape, location, pitch: snap, rub, click), radiates
Neck/Nodes: denies pain, stiffness, masses, swelling, swollen glands to carotid
Psychology: denies suicidal ideation, depression, history of mental
Breast/Axilla: denies lumps, discharge, pain, tenderness, dimpling, illness, anxiety, depression GI: +BS, soft, non-tender, auscultate sounds, murmurs, rubs, percuss
contour changes, nipple changes tympany/dullness, organomegaly, ascites, palp guarding, tenderness
Physical Exam: rebound, hernias
‫܆‬SBE: When, how often, last mammography, date and provider
PMH: Vitals: BP: HR: RR: SaO2: T: Vascular: no ____ R/L pitting edema
Respiratory: denies cough, sputum production, hemoptysis, chest pain, HT: WT: BMI:
shortness of breath, wheezing, asthma, bronchitis, pneumonia, Pulses:
emphysema, date of last CXR, date of PPD and results. General: AAOx3, mood ______, adult, gender ______, in no acute DP PT POP FEM RADIAL
distress, ‫܆‬nutritional status, ‫ ܆‬personal hygiene, ‫ ܆‬posture, Right
Cardiovascular: denies chest pain or tightness, palpitations, dyspnea, ‫ ܆‬anxiety, ‫ ܆‬appears stated age Left
murmur, edema, paroxysmal nocturnal dyspnea, known heart
PSH: murmur, date of last EKG and results, date of cardiology consult and Skin: ‫ ܆‬texture, color, temperature, turgor, any lesions Genital/Rectum: ‫܆‬N/A ‫܆‬deferred
provider. ‫ ܆‬Note hair distribution, amount, hair texture
‫ ܆‬Note color of nail beds and shape of nails Musculoskeletal: muscles, joints, symmetry, swelling, DTR, ROM,
GI: denies Anorexia, nausea, vomiting, dysphagia, indigestion,
belching, heartburn, hematemesis, abdominal pain, ulcers, jaundice, tenderness, pain/pressure
SH: Head: Note size, shape, symmetry, unusual lesions
‫ ܆‬ETOH (kind ______, amount _____ x day/week/month) food intolerance, diarrhea, constipation, change in bowel habits,
bloody or tarry stools, pain or rectal itching, rectal bleeding. Last Neuro: vibration, touch, pain, temp, strength, rapid-alternative
‫ ܆‬Smoking ( ___PPD x ____ yrs) ‫ ܆‬quit? When? ________ Eye: Position and alignment, eyebrow, eyelidslacrimal glands, cornea, movements,
rectal exam, Guiac and results
‫܆‬Recreational drugs (kind _____, amt _____, duration_______) sclera (jaundice), conjunctiva (color, injection), cornea, pupils
‫ ܆‬Married / Divorced / Single / Children # GU: denies frequency, urgency, burning, dysuria, hematuria, ‫ ܆‬Test visual fields, pupillary reaction ! PERRLA (pupils equal, EKG: Date: Interpretation:
‫ ܆‬Retired / Career ______________ nocturia, incontinence, change in color or odor, dribbling, retention, round, reactive to light and accommodation), EOMI (extra ocular
oliguria. ADL: Urinary pattern, urology consult, date of exam and movements intact), nystagmus Labs: Date:
Meds/OTC/Herbals: provider ‫ ܆‬Fundoscopic exam: cataracts, red reflex, optic disc, vessels:
papilledema, hemorrhages, retinopathy WBC Hgb Plt

‫ ܆‬Male Genital: Weak urine stream, discharge from penis, lesions, ‫ ܆‬Snellen chart Hct

testicular pain or swelling, lumps on testicles, sexual dysfunction, STD’s.

ADL: TSE, use of condoms, sexuality Ears: Inspect auricles, canals, TM Date/Diagnostics/Results
‫ ܆‬Auditory acuity (whispering, clapping)
Allergies/Reactions: NKDA ‫܆‬Female Genital: Menstrual history, (age of onset, frequency of ‫ ܆‬Weber (forehead, equidistant, which ear is the sound louder? Na Cl Bun Glu
menses, duration of menses), LMP, menorrhagia, metrorrhagia, post- Lateralization to left or right?) unilateral conductive loudest in affective K HCO3 Cr GFR ASA:
FMH: mother/father/siblings/grandparents/children menopausal bleeding, amenorrhea, dysmenorrhea, vaginal discharge, ear Mallampati:
lesions on vulva, vulva pruritus, pregnancies, (Gravida-Para-Abortions- ‫ ܆‬Rinne (normal AC > BC +Rinne, conductive AC < BC –Rinne, CHADS2:
M Live births), dyspareunia, STD’s sensorineural AC > BC +Rinne )
F Age of menarche: _____ ‫܆‬Number of pregnancies: G Ca Mg
PT INR
Nose/Sinuses: Inspect normal nose, septum, nasal mucosa.
Review of Systems: Flow/Frequency of menses: ______ ‫܆‬Number of Term >20wks: T
Pain/pressure frontal/maxillary sinuses Phos PTT
Duration of menses: _______ ‫܆‬Number of Preterm <20 wks: P
General: denies fatigue, loss/increase appetite, weight change, Exposure to DES: ‫܆‬ ‫܆‬Number of abortions/miscarriages: A
Mouth/Throat: Jaw motion, lips, salivary glands, cheeks, tongue, teeth,
weakness, fever, chills, night sweats Complications of pregnancies: ‫܆‬ ‫܆‬Number of Living: L Impression:
gums, oral mucosa, pharynx, soft/hard palate, tonsils
Head: denies lumps, asymmetry, syncope, headache, dizziness, ADL: Last GYN exam, date and result of last pap smear, birth control Assessment Plan w/ Rationale
vertigo, recent trauma Neck/Nodes: ‫ ܆‬neck, supple, no masses, trachea midline, no 1.
Vascular: denies edema, phlebitis, calf pain, intermittent carotid bruits
2.
Eyes: denies pain, redness, itching, burning, discharge, swelling, claudication, varicose veins, emboli ‫ ܆‬Note size, consistency, mobility, tenderness: preauricular,
3.
excessive tearing, blurring of vision, diplopia, spots, photophobia, postauricular, occipital, tonsillar, submandibular, submental, superficial
anterior cervical, supraclavicular, deep cervical 4.
changes in vision or visual fields, glasses/corrective lenses/contact Musculoskeletal: denies pains in joints, swelling, heat, redness,
lens, date of last eye exam and name of provide stiffness, muscle weakness, muscle aching or pain, back pain or injury, ‫ ܆‬Thyroid gland: visible, symmetrical. Note size, symmetry, position of 5.
limitation in movement, ROM lobes, presence of nodules. Usually unpalpable. No goiter/nodules

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