Full H & P - CALTCM
NAME: ____________________________________ DATE:___/___/___
HPI SOURCE: ___Pt. ___Pt./Assist. ___Limited Pt. Input Age Sex Race ________
Former Occupation Marital Status_______ Education_________________
Reason For Admission ____________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
PAST MEDICIAL HISTORY
Chronic Illnesses
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Prior Surgeries
______________________________________________________________________________________________
CURRENT MEDS: (include OTC) HABITS: NO YES AMOUNT
_________________________ ____________________________ _________ ETOH__________
_________________________ ____________________________ _________ SMOK _________
_________________________ ____________________________ _________ CHEW TAB_____
_________________________ ____________________________ _________ OTHER________
_________________________ ____________________________ VACCINES:
_________________________ ____________________________ PNEUMOVAX _________ _________________________ ____________________________ FLU _________ Hx TB ________
Allergies:________________________________________________ TET TOX _________ RX _________
SOCIAL: (Living Situation, Support. Usual Day's Activities)______________________________________________________
________________________________________________________________________________________________________
ROS:
___ Anorexia ___ Visual impair ___ PND/Orthop ___ Constipation ___ Dizziness
___ Fatigue ___ Hearing Impair ___ Chest Pain ___ Bowel Incont ___ Depression
___ Wt Change ___ Dental ___ Resp Diff ___ Bladder Incont ___ Falls
___ Insomnia ___ Prostatism ___ Edema ___ Vag Bleed ___ Focal Neuro
___ Skin rash ___ Impotence ___ Dysuria ___ Nocturia ___ Forgetful
________________________________________________________________________________________________________
________________________________________________________________________________________________________
PHYSICAL EXAM: WT_____ HEIGHT_______ BP___/___ TEMP_____ HR____ RESP ____
GEN HEAD EYES
EARS NOSE
FACE THROAT MOUTH
NECK THYROID
BREAST
CHEST CARD
ABDOMEN
MUS/SKE
GU RECTAL
SKIN
EXT BACK
NEURO MOTOR
CEREBELLAR SENSORY
CN’s:_______________________________________________________________________________
PROBLEM LIST RECOMMENDATIONS :
1)_____________________________________________ ______________________________________________________
2)_____________________________________________ ______________________________________________________
3)_____________________________________________ ______________________________________________________
4)_____________________________________________ ______________________________________________________
5)_____________________________________________ ______________________________________________________
6)_____________________________________________ ______________________________________________________
Based on my assessment of this patient’s mental status...
_____ He/She is competent to understand his/her medical condition and patient’s bill of rights as presented by the staff.
_____ He/She is currently competent, but has a history of intermittent confusion which may impair understanding.
_____ He/She is not competent to understand his/her medical condition and patient/s bill of rights, therefore the staff is instructed to present this information to a family member, guardian, or conservator.
PROGNOSIS __________________________ REHABILITATION POTENTIAL ________________________________
I, ________________________, acknowledge that I have discussed the patient’s condition with the patient, or his/her responsible party. _____Yes _____No If, “No”, explain ________________________________________
Signatures: Print Name ______________________ Signature_______________________________________ Date:___/___/___
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