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Chief Complaint
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Time seen:
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Onset:
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Chronic Conditions/Past Medical History
• • •
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Other:
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Family History
• • •
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Surgical History
• • •
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Other:
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Social History
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Tobacco
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How many packs per day:
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Smoking quit date:
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Alcohol:
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How many drinks per day:
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Illicit Drugs:
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Allergies
• • •
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Other
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Pain:
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Last Menses:
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P:
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G:
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Ab:
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Pregnant:
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EDC:
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Flu Shot:
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Vaccines UTD:
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Last TD:
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Section II to be completed by MD/PA/NP
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History of Present Illness
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Time seen by MD/PA/NP:
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Review of Systems:
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Const:
• • •
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Neuro:
• • •
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Head:
• • •
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Eyes:
• • •
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Skin:
• • •
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Musc-Ske:
• • •
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Psych:
• • •
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Cardio:
• • •
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Resp:
• • •
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G.I:
• • •
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G.U:
• • •
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Endo:
• • •
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Practitioner Orders:
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Time Done:
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Ints:
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Practitioner Orders:
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Time Done:
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Ints:
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Practitioner Orders:
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Time Done:
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Ints:
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Practitioner Orders:
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Time Done:
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Ints:
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Practitioner Orders:
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Time Done:
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Ints:
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Tests
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RST:
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Results:
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UA:
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Results:
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HCG:
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Results:
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Glucose:
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Results:
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Flu:
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Results:
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EKG:
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Results:
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PFT:
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Results:
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pk Flow:
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Results:
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Guiauc:
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Results:
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Vision:
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Results:
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Communications:
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Preferred Pharmacy:
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Physical Exam
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Eyes Normal
• • •
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Eyes Abnormal
• • •
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Comments
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ENT Normal
• • •
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ENT Abormal
• • •
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Comments
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Neck Normal
• • •
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Neck Abnormal
• • •
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Comments
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LN's Normal
• • •
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LN's Abnormal
• • •
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Comments
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Resp Normal
• • •
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Resp Abnormal
• • •
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Comments
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Cardio Normal
• • •
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Cardio Abnormal
• • •
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Comments
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Breast Normal
• • •
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Breast Abnormal
• • •
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Comments
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GI/Abd Normal
• • •
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GI/Abd Abnormal
• • •
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Comments
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GU Female Normal
• • •
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GU Female Abnormal
• • •
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Comments
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GU Male Normal
• • •
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GU Male Abnormal
• • •
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Comments
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Skin Normal
• • •
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Skin Abnormal
• • •
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Comments
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Neuro Normal
• • •
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Neuro Abnormal
• • •
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Comments
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Psych Normal
• • •
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Psych Abnormal
• • •
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Comments
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Muscular/Skeletal Normal
• • •
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Muscular/Skeletal Abnormal
• • •
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Inspection:
• • •
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Palpation:
• • •
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Strength:
• • •
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Comments
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Laceration
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Location:
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Description: Length (cms):
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Please Select:
• • •
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Wound cleaned with:
• • •
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Wound anesthesized with:
• • •
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Suture Material:# Sutures:
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# Staples:
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Please Select:
• • •
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Dressing:
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Splint:
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Procedure Note
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Physical Exam Pertinent Findings
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Prescriptions Given
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Discharge Plan/Instruction/Follow Up
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RTO in___ day no improvement:
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Levels
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Straightforward:
• • •
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Low Complexity:
• • •
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Reason for Complexity:
• • •
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Mod Complexity:
• • •
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Reason for Complexity:
• • •
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High Complexity:
• • •
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Reason for Complexity:
• • •
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Disposition:
• • •
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Referral:
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Condition:
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