American College of Physicians | Internal Medicine | ACP



Patients Name: ____________________________________

Adult Summary Form Date of Birth: _____________________________________

Medical Record #: _________________________________

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Primary Care Provider: ________________________________________________________________________

Drug Allergies/Sensitivities: ___________________________________________________________________

Emergency Phone #: _______________________ Contact Person/Relationship: __________________________

|ICD Code |Chronic Medical Problem List |Date |Past Surgical History |Date |

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| | | |Hospitalizations |Date |

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|Family History of |Initial Risk Assessment |Social History |

|Y N Family Member | | |

|( ( Alzheimer’s Dz ______________ |Date |( Married ( Single ( Civil Union |

|( ( Breast Ca ______________ | | |

|( ( CAD ______________ |( Alcohol/Drug Use _________ |( Divorced ( Widow(er) |

|( ( Cerebrovas. Dz ______________ |( STDs _________ | |

|( ( Cervical Cancer ______________ |( Domestic Violence _________ |( Lives Alone ( Separated |

|( ( Colon CA ______________ |( Depression _________ | |

|( ( Depression ______________ |( Osteoporosis _________ |Occupation: ______________________ |

|( ( DM ______________ |( Geriatric Assessment _________ | |

|( ( Fe Storage ______________ |( MMSE _________ |Religious Preference: ______________ |

|( ( Glaucoma ______________ |( ________________ _________ | |

|( ( Hyperchol. ______________ | |Advance Directive? ( Yes ( No |

|( ( HTN ______________ | |If Yes, Date: _________________ |

|( ( Ovarian CA ______________ | | |

|( ( Prostate CA ______________ | |Educ.: ( JHS ( HS ( College |

|( ( Skin CA ______________ | | |

|( ( Thyroid Dz ______________ | |( Other _________________ |

Signature: ____________________________________________________________ Date: _________________________

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