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Requesting Physician and Service
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Consult Performed By
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Reason for Consult/Chief Complaint
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History of Present Illness
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HPI Additional Info
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Past Medical History
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Diagnosis
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Diagnosis
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Diagnosis
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Diagnosis
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Past medical history pertinent negatives
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Pertinent Negatives
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Family History
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Problem
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Relation
• • •
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Problem
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Relation
• • •
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Problem
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Relation
• • •
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Problem
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Relation
• • •
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Social History
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Marital Status
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Spouse Name
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Number of Children
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Smokinig Status
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Packs/day
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Years of education
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Smokeless tobacco
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Alcohol Use
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Drug Use
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Sexual Activity
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Other Topics
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Concern
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Social History Narrative
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Review of Systems
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Constitutional
• • •
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Constitutional (-)
• • •
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Eyes
• • •
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Eyes (-)
• • •
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Ears/Nose/Mouth/Throat
• • •
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Ears/Nose/Mouth/Throat (-)
• • •
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Cardiovascular
• • •
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Cardiovascular (-)
• • •
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Respiratory
• • •
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Respiratory (-)
• • •
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Gastrointestinal
• • •
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Gastrointestinal (-)
• • •
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Genitourinary (+)
• • •
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Genitourinary (-)
• • •
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Musculoskeletal
• • •
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Musculoskeletal (-)
• • •
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Integumentary
• • •
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Integumentary (-)
• • •
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Neurological
• • •
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Neurological (-)
• • •
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Psychiatric
• • •
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Psychiatric (-)
• • •
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Endocrine
• • •
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Endocrine
• • •
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Hematologic
• • •
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Hematologic
• • •
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PHYSICAL EXAMINATION
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General Appearance
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Explain Abnormalities
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Conjunctivae and eyelids
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Explain Abnormalities
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Lips, Teeth and Gums
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Explain Abnormalities
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Oropharynx
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Explain Abnormalities
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Neck, Thyroid
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Explain Abnormalities
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Peripheral Vascular System
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Explain Abnormalities
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Abdomen
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Explain Abnormalities
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Lymph Nodes
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Explain Abnormalities
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Digits and nails
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Explain Abnormalities
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Scalp and hair
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Explain Abnormalities
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Skin of head and face
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Explain Abnormalities
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Skin of neck
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Explain Abnormalities
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Skin of chest
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Explain Abnormalities
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Skin of abdomen
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Explain Abnormalities
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Skin of genitalia, groin, buttocks
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Explain Abnormalities
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Skin of back
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Explain Abnormalities
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Skin of right upper extremity
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Explain Abnormalities
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Skin of left upper extremity
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Explain Abnormalities
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Skin of right lower extremity
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Explain Abnormalities
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Skin of left lower extremity
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Explain Abnormalities
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Eccrine and apocrine glands
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Explain Abnormalities
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Orientation to time, place and person
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Explain Abnormalities
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Explicit verbal consent for photography was obtained from the patient on the day of service.
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Exam was remarkable for:
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Review of Other Clinical Data
• • •
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Independent Review of Images/Tracings
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Assessment & Plan
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Assessment & Plan - Reference
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Assessment & Plan: additional information
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