HISTORY AND PHYSICAL EXAMINATION FORM …
*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
*760600*
Osteopathic Musculoskeletal Examination of the Hospitalized Patient (Revised)
Examiner (print)
Chief Complaint:
INSTRUCTIONS: Complete Boxes #1-3 (#4 Peds Only)
1 Ant./Post. Spinal Curves: I N D
Cervical Lordosis 0 0 0 Thoracic Kyphosis 0 0 0 Lumbar Lordosis 0 0 0
I = Increased: N = normal: D = decreased.
Scoliosis (Lateral Spinal Curves)
0 None
sitting 0
0 Functional 0 Mild 0 Moderate 0 Severe
standing 0
prone/ supine
0
lat. recumb. 0
unable to 0
examine
2
Severity Key:
Assessment Tools:
t = No SD or background (BG) levels
u = Minor TART more than BG levels
v = TART obvious (R & T esp) +/- symptoms
w = Symptomatic, R and T very easily found, "key lesion"
0 T = Tenderness 0 A = Asymmetry 0 R = Restricted Motion
0 Active 0 Passive 0 T = Tissue Texture Change
?
Region Evaluated
Head Neck Thoracic T1-4
T5-9
SEVERITY
0123 0000 0000 0000 0000
Specifics of Major Somatic Dysfunctions
T10-12
0000
Lumbar
0000
Pelvis/Sacrum
0000
Pelvis/Innominate 0 0 0 0
Extremity (lower) Extremity (upper) Ribs
R 0000 L 0000 R 0000 L 0000
0000
Other / Abdomen 0 0 0 0
3
Somatic Dysfunctions Correlate with:
0 Traumatic
0 Orthopedic
0 Neurological
0 Viscero
somatic
0 Primary
Ms-Skeletal
0 Activities of
daily living
0 Other
0 Rheumatological 0 EENT 0 Cardiovascular 0 Pulmanary
0 Gastrointestinal
0 Genitourinary
0 Congenital
4 PEODNSLY
a. Cranium: Fontanelles:
Patent/closed Overriding Sutures: Present/absent
b. Ambulation walks crawls
sits unassisted rolls over
Signature of the examiner:
Date of Examination:
................
................
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