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Medical History
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Past Medical History
• • •
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Past Medical History Freewrite
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Past Surgical History
• • •
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Past Surgical History Freewrite
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Any Hospitalizations or Surgical Procedures?
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Free Write
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Family History
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Family HX
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Father's MH
• • •
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Mother's MH
• • •
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Sibling(s)' MH
• • •
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Medication and Immunizations
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does this person take medications independently?
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Free Write
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is this person free of communicable diseases?
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Free Write
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immunizations
• • •
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Free Write
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TB screening method
• • •
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TB screening positive?
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if TB screening positive, chest x-ray ordered?
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medical and diagnostic tests FEMALE
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woman over age 18, gyn exam with Pap smear
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date and results of Pap smear
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mammogram Q 2 yrs, Age 40-49, yrly 50 +
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date and results of mammogram
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hemoccult
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date and results
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urinalysis
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date and results
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CBC and differential
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date and results
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hepatitis-B screening
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date and results
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any other tests
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Medical and Diagnostic tests MALE
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prostate exam age 40 and over
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date and results
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PSA
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date and results
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Evaluation of Systems
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Eyes Yes / No
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Ears Yes / No
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Nose Yes / No
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Mouth Throat Yes / No
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Head/Face/Neck Yes / No
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Breasts Yes / No
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Eyes Yes / No
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