History & physical long form / comprehensive - UCLA Health
HISTORY & PHYSICAL LONG FORM / COMPREHENSIVE
(Comprehensive H&P required for all admissions > 24 Hours
Date: Chief Complaint:
Time:
History of Present Illness:
MRN: Patient Name:
Service:
(Patient Label)
Allergies:
Medications:
Past Medical History: (N/C = non-contributory) N/C
CAD
CVA
HTN
DM
Other:
Past Surgical History: N/C
Family History: N/C Relevant Social History:
N/C
ETOH
IVDA
Tobacco _____ Packs x ______ yrs
Review of Systems CHECK ALL APPROPRIATE BOXES
GENERAL:
WNL Other
SKIN:
WNL Other
ENT:
WNL Other
EYES:
WNL Other
CV:
WNL Other
RESP: GI:
WNL WNL
Other Other
GU:
WNL Other
Muscl: Neuro:
WNL WNL
Hemat/Lymph:
WNL
Examining Practitioner: Attending MD:
Other Other Other
UCLA Form #316042 Rev. (7/13)
Date: Date:
Time: Time:
Pager #: Pager #:
Page 1 of 2
MRN: Patient Name:
HISTORY & PHYSICAL LONG FORM / COMPREHENSIVE
(Comprehensive H&P required for all admissions > 24 Hours
Allergic/Immuno:
Endo: Psych: Other:
WNL
Reactions to:
Trouble breathing
WNL
Diabetes
WNL
Nervousness
Drugs
Food
Persistent infections
Thyroid Dysfunction
Anxiety
Depression
(Patient Label)
Insects HIV exposure
Skin rashes
Previous psych care
Hallucinations
Physical Exam: CHECK ALL APPROPRIATE BOXES
General:
WNL
Other
ENT:
WNL
Other
Eyes: Breasts:
WNL WNL
Other Other
Lungs:
WNL
Other
Heart: Abd:
WNL WNL
Other Other
MusculoSkeletal: Genitalia:
Neurologic:
Skin/wounds:
WNL
WNL WNL WNL
Other
Other Other Other
Vital Signs: B/P Height: _____________
P
R
T
Weight: ______________
Labs: Impression:
Studies: CXR: EKG:
Plan:
Examining Practitioner: Attending MD:
UCLA Form #316042 Rev. (7/13)
Date: Date:
Time: Time:
Pager #: Pager #:
Page 2 of 2
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