|
PCP
|
History of Present Illness
|
|
Location
• • •
|
Location Comments
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|
Quality
• • •
|
Quality Comments
|
|
Severity
|
Severity Comments
|
|
Duration
• • •
|
Duration Comments
|
|
Onset / Timing
• • •
|
Onset Comments
|
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Context
• • •
|
Context Comments
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|
Medical History
|
Past Medical History
• • •
|
|
Family History
|
Past Surgical History
• • •
|
|
Social History
|
Smoking status
|
|
|
Alcohol
|
|
REVIEW OF SYSTEMS
|
|
|
General [-]
|
General
• • •
|
|
Skin [-]
|
Skin
• • •
|
|
Neck [-]
|
Neck
• • •
|
|
Cardiovascular [-]
|
Cardiovascular
• • •
|
|
Respiratory [-]
|
Respiratory
• • •
|
|
GI [-]
|
GI
• • •
|
|
Periph. Vasc. [-]
|
Periph. Vasc.
• • •
|
|
MSK [-]
|
MSK
• • •
|
|
Neurological [-]
|
Neurological
• • •
|
|
Psychiatric [-]
|
Psychiatric
• • •
|
|
PHYSICAL EXAM
|
|
|
General WNL
|
General Abnormal
• • •
|
|
Skin WNL
|
Skin Abnormal
• • •
|
|
Neck WNL
|
Neck Abnormal
• • •
|
|
Cardiovascular WNL
|
Cardiovascular Abnormal
• • •
|
|
Lungs WNL
|
Lungs Abnormal
• • •
|
|
Abdomen WNL
|
Abdomen Abnormal
• • •
|
|
MSK WNL
|
MSK Abnormal
• • •
|
|
Neuro WNL
|
Neuro Abnormal
• • •
|
|
Extremities WNL
|
Extrem Abnormal
|
|
Assessment
|
Non Invasive Vascular Lab Studies
• • •
|
|
Radiology
• • •
|
Diet
|
|
General Instructions
• • •
|
General Instruction Comments
|
|
billing
|
|
