HISTORY AND PHYSICAL EXAMINATION FORM HOSPITAL …

*760600*

HISTORY AND PHYSICAL EXAMINATION FORM HOSPITAL ADMIT NOTE

PATIENT NAME

DATE OF BIRTH

DATE COMPLETED

DEMOGRAPHICS CARE SETTING:

c OUTPATIENT c ER ADMIT c DIRECT ADMIT c PAT c OTHER

ADMIT FORM: c N/A c HOME c ECF c OFFICE c OTHER FACILITY

REFERRING:

DO/MD OFFICE PHONE

MANAGED CARE PLAN: BCN WELLNESS SELECTCARE NONE OTHER

CONTACT PERSON:

REL

PHONE

ADVANCED DIRECTIVES: c ON CHART c NONE DPOA:

PHONE

CODE STATUS:

c FULL c NO CODE c LIMITED

CHIEF COMPLAINT Informant: c Patient c Relative

c Other

HISTORY OF PRESENT ILLNESS

CURRENT MEDICATIONS c NONE (include OTC, supplements, drops, inhalants, patches, oxygen) ALLERGIES/ADVERSE DRUG REACTIONS c NKDA (specify reaction) *760600 (05/07)

PAST MEDICAL HISTORY

PAST SURGICAL HISTORY (include name of surgeon, hospital and date for each procedure)

SOCIAL HISTORY c HAVE YOU SMOKED WITHIN THE LAST 12 MONTHS?

Tobacco c NONE c ACTIVE c QUIT

PK/YRS:

c SMOKELESS c QUIT ATTEMPTS

Alcohol

c NONE FREQUENCY

LAST DRINK

HX DT/DETOX:

Caffeine

Illicit drugs c NONE TYPE(S):

Occupation

Exposures

Living situation

Travel

Diet

Nutrition counseling

Exercise

Other

IMMUNIZATION STATUS N=never U=unknown or list year last given - include in plan if update needed

Tetanus

Pneumovax

Influenza

Hepatitus B

Varicella

PPD

Childhood

FAMILY MEDICAL HISTORY Parents

Siblings

Other REVIEW OF SYSTEMS c Unable to obtain ROS due to

1. GENERAL

Fever

Chills

Anorexia

Diaphoresis

Weight gain

Weight loss

2. ENDOCRINE/METABOLIC Throid disorder Temp intolerance

Radiation exposure Diabetes

3. HEMATOLOGIC

Anemia

Sickle cell

Transfusions

Bruising

c No abnormals Adenopathy Lightheadedness

Edema

c No abnormals Goiter

Lipid disorder

c No abnormals Leukemia Bleeding

Line through negatives; circle positives and describe

4. SKIN

Pruritus

Rash

Skin cancer

Tattoos

c No abnormals Mole changes Hair or nail changes

5. EYES

Corrective lenses Cataracts

Photophobia

Visual change

c No abnormals Glaucoma Laser surgery

6. ENT

Infections

Hearing loss

Tinnitus

Epistaxis

c No abnormals Vertigo Hoarseness

7. ORAL

Condition of teeth Dentures

Pain

Infections

c No abnormals Lesions Dysgeusia

8. CARDIOVASCULAR

Chest pain

Chest pressure

Syncope

Orthopnea

MI

Hypertension

Murmur

Rheumatic fever

Claudication

Aneurysm

DVT/PE

Thrombophlebitis

c No abnormals Palpitations PND Cardiac cath Dysrhythmia Varicosities Raynaud's

9. PULMONARY

Dyspnea

Cough

Asthma/COPD Wheezing

Positive PPD

TB exposure

c No abnormals Hemoptysis Tuberculosis

10. BREASTS

c No abnormals

Mass

Tenderness

Discharge

Asymmetry

Gynecomastia Implants

Mammograohy (include dates and provider

11. GASTROINTESTINAL

c No abnormals

Dysphagia

Odynophagia

Heartburn

Abdominal pain Nausea/vomiting Hematemesis

Hematochezia

Melena

Diarrhea

Constipation

Ulcers

Hepatitis

Pancreatitis

Gallstones

Colitis

Jaundice

Hemorrhoids

Hernia

Fecal occult blood/endoscopy (include dates and results)

12. MUSCULOSKELETAL

Pain

Arthritis

Stiffness

Swelling

c No abnormals Deformity Injury

13. NEUROLOGIC

Paresthesia

Paralysis/paresis

Head trauma

Syncope

Seizures

Tremor

Gait abnormality Dysarthria

c No abnormals Headache CVA/TIA Weakness

14. PSYCHIATRIC

Anxiety

Depression

Memory loss

Psych treatment

c No abnormals Psychosis

15. GENITOURINARY

Hematuria

Dysuria

Frequency

Nocturia

Change in stream Infection

c No abnormals Urgency Incontinence Nephrolithiasis

16. GENITOREPRODUCTIVE

c No abnormals

ALL

Multiple partners STD's

MALE Impotence

Testicular self exam

FEMALE Abnormal bleeding

Hormone use

Pain

Mass

Penile discharge

Dyspareunia PMS

Contraception Infertility

17. OB/GYN: complete below G____P ___ ___ ___ ___ FDLMP

Menarche

Menopause

PHYSICAL EXAMINATION

*760600*

VITALS Temp

HR /min RR /min BP supine

BP seated/standing

Height

Weight

lb / kg (actual / est) Pulse ox

% on

Pain

1. GENERAL Status Skin color Orientation

2. EYES Pupils Fundus

3. ENT Head EAC Nasel Mucosa Pharynx

4. NECK Mobility Thyroid

5. LUNGS Wheeze Rales Dullness

6. HEART Rate Heart sounds Rub

7. VASCULAR Pulses Stasis Edema

8. ABDOMEN Bowel sounds Distension

9. RECTAL Sphincter tone Hemorrhoids

10. NEURO Cranial nerves Meningismus Muscle strength Sensation

11. LYMPH Cervical Supraclavicular Inguinal

12. SKIN Turgor

13. BREASTS Skin changes Mass Asymmetry

14. GENITAL Male: Female:

General appearance Acutely / chronically ill Level of consciousness

c No abnormals Conjunctiva Extraocular motion

c No abnormals Hearing Tympanic membranes Gums and teeth Tongue

c No abnormals Trachea Masses

c No abnormals Rhonchi Friction rub Abnormal breath sounds

c No abnormals Rhythum Murmur PMI

c No abnormals Bruits Varicosities Capillary refill

c No abnormals Tenderness Abnormal percussion

c No abnormals Masses Gross/occult blood

c No abnormals Cerebellar function Deep tendon reflexes Pathologic reflexes Fine motor

c No abnormals Occipital Axillary Epitrochlear

c No abnormals Lesions

c No abnormals Nipple inversion Tenderness Discharge

c No abnormals

Penis Urethra

Testicles

Prostate

External

genitalia

Urethra

Vagina

Adnexa

Uterus

c Not done c Not done

c Not done c Not done c Not done c Not done c Not done c Not done c Not done

c Not done c Not done c Not done c Not done

Cervix

Circle abnormals and describe. If exam not done, document reason. If patient refuses exam, document that risks of not completing exam were discussed with patient.

DIAGNOSTIC FINDINGS

Other IMPRESSIONS

UA EKG RAD

PLAN

Print name

Signature

Date

Pager

Reviewed by

(Int/Res) Signature

Pager

ATTENDING PHYSICIAN STATEMENT: I have personally interviewed and examined this patient

and have reviewed this history and physical examination c I agree with H&P as stated c I have made corrections as indicated above or in progress notes

Signature of attending

Date reviewed

PREVENTION COUNSELLING Check "D" if discussed and include in plan as needed. Check "N/A" if not applicable.

D N/A c c c c c c c c c c c c c c c c c c

General Dietary recommendations Seat belts Exercise Smoking cessation Immunizations Gun safety Helmets (bicycle, motorcycle, rollerblading) Safe sex practices Injury prevention

D N/A c c c c c c c c c c c c c c c c c c

Disease prevention Breast self examination Menopausel health Mammography PAP smears Testicular self exam Prostate screening Osteoporosis prevention Colon cancer screening Other

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