Family Practice History and Physical



WCMA Office Visit

|cc: |

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|HPI: |

|PMH |PSH |

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|Reviewed and unchanged |Reviewed and unchanged |

|GYN G_____P__________ LMP |

|Allergies see chart/reviewed |

|SH Tobacco: Exercise: |FH Mother: |

|ETOH: Drugs: |Father: |

|Vocation: |Other: |

|Living Situation: CODE STATUS ___________ | |

|Reviewed and unchanged |Reviewed and unchanged |

|ROS (Check = normal, circle = abnormal) |Physical Exam (Check = normal, circle = abnormal) |

|Gen No fever, chill, wt loss, fatigue | |Gen WN, NAD | |

|HEENT No HA/visual change/hearing loss | |HEENT AT/NC, PERRL, EOMI, TM’s clear, OP without | |

|Odynophagia, dysphagia, epistaxis | |erythema or exudate | |

|Pulmonary No ShOB, wheeze, hemoptysis, cough | |Neck Supple, No JVD, carotid bruits, TM | |

|Cardiac No CP/DOE/PND/LE swelling/palpitations | |Lungs CTA, no wheeze, rales, rhonchi | |

|GI No melena/hematochezia/abd pain/n/v/d | |CV RRR, S1S2, No M/R/G, no LE edema | |

|GU No dysuria/hematuria/polyuria/discharge/flank pain | |Chest Normal breasts, no nipple D/C | |

|MSK No joint or muscle pain | |GI S/NT/ND/BS+ no HSM, masses or rebound | |

|Neurological No weakness/numbness/sz/CVA/TIA | |GU NL male/ female exam | |

|Endocrine No thyroid disease or diabetes | |Rectal Heme negative, normal prostate | |

|Hematologic No easy bruising or bleeding | |Lymph Neck, Axilla, Groin | |

|Psychiatric No h/o anxiety, depression, mental illness | |MSK strength 5/5, tone, gait, FROM | |

|Allergies: No hayfever, runny nose | |Back neg. SLR test x2, no scoliosis, no spasm | |

|Skin: No rash | |Neuro CN 2-12, sensation, FTN, DTR 2+ | |

| | |Skin no rash | |

| | |Psych normal affect, judgment, mood A&O x3 | |

| | |Pulses Dorsalis Pedis, Radial, femoral 2+ | |

|ABNORMAL ROS: |ABNORMAL PHYSCIAL EXAM FINDINGS: |

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|Assessment and Plan: |

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|LABS/samples: |Follow-up ___________________ |

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|Medication risks/benefits/costs/alternatives discussed with patient |PRN |

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