|
Age:
|
Pain (0-10 Scale)
|
|
Review of PMH
|
Changes
|
|
Review of FMH
|
Changes
|
|
Sexually Active
|
|
|
Number of Partners
|
Male/Female/Both
|
|
Smoker
|
Drug Use
|
|
Review of Systems
|
|
|
HEENT Normal
|
HEENT Normal
• • •
|
|
Description of Abnormal
|
|
|
Urogenital System
|
Urogenital System
• • •
|
|
Description of Abnormal
|
|
|
Gastrointestinal
|
Gastrointestinal
• • •
|
|
Description of Abnormal
|
|
|
Cardiovascular
|
Cardiovascular
• • •
|
|
Description of Abnormal
|
|
|
Musculoskeletal
|
Musculoskeletal
• • •
|
|
Description of Abnormal
|
|
|
Breasts
|
Breasts
• • •
|
|
Description of Abnormal
|
|
|
Pulmonary - Normal
|
Description of Abnormal
|
|
Neurologic
|
Neurologic
• • •
|
|
Neurologic
|
|
|
Psycological
|
Psycological
• • •
|
|
Description of Abnormal
|
|
|
Integumentary System - Normal
|
Description of Abnormal
|
|
Genitalia (ext)
|
Genitalia (ext)
• • •
|
|
Description of Abnormal
|
|
|
Rectal/Prostate
• • •
|
Description of Abnormal
|
|
Sexually Transmitted Disease Screen
|
|
|
Hemacult
|
Results
|
|
Colonoscopy
|
Results
|
|
EKG
|
Results
|
|
CXR
|
Results
|
|
Labs
|
|
|
Other Screening
• • •
|
Other
|
|
Patient Education
• • •
|
|
|
Diagnosis
|
Plan
|
