|
Does the Patient Have any complaints? if yes then do not use this form and inform frontdesk
|
|
|
Medical History
|
|
|
Past Medical History
• • •
|
Past Medical History Freewrite
|
|
Past Surgical History
• • •
|
Past Surgical History Freewrite
|
|
Any Hospitalizations or Surgical Procedures?
|
Free Write
|
|
Family History
|
|
|
Family HX
|
|
|
Father's MH
• • •
|
|
|
Mother's MH
• • •
|
|
|
Sibling(s)' MH
• • •
|
|
|
Medication and Immunizations
|
|
|
does this person take medications independently?
|
Free Write
|
|
is this person free of communicable diseases?
|
Free Write
|
|
immunizations
• • •
|
Free Write
|
|
TB screening method
• • •
|
TB screening positive?
|
|
if TB screening positive, chest x-ray ordered?
|
|
|
medical and diagnostic tests FEMALE
|
|
|
woman over age 18, gyn exam with Pap smear
|
date and results of Pap smear
|
|
mammogram Q 2 yrs, Age 40-49, yrly 50 +
|
date and results of mammogram
|
|
hemoccult
|
date and results
|
|
urinalysis
|
date and results
|
|
CBC and differential
|
date and results
|
|
hepatitis-B screening
|
date and results
|
|
any other tests
|
|
|
Medical and Diagnostic tests MALE
|
|
|
prostate exam age 40 and over
|
date and results
|
|
PSA
|
date and results
|
|
Evaluation of Systems
|
|
|
Eyes Yes / No
|
Ears Yes / No
|
|
Nose Yes / No
|
Mouth Throat Yes / No
|
|
Head/Face/Neck Yes / No
|
Breasts Yes / No
|
|
Lungs Yes / No
|
Cardiovascular Yes / No
|
|
Extremities Yes / No
|
Abdomen Yes / No
|
|
Gastrointestinal Yes / No
|
Musculoskeletal Yes / No
|
|
Skin Yes / No
|
Renal/Urinary Yes / No
|
|
Reproductive Yes / No
|
Lymphatic Yes / No
|
|
Endocrine Yes / No
|
Nervous System Yes / No
|
|
Vision Screening Yes / No
|
Is further evaluation recommended by specialist Yes / No
|
|
Hearing Screening Yes / No
|
Is further evaluation recommended by specialist Yes / No
|
|
Additional Comments
|
|
|
Medical History, Summary Reviewed Yes / No
|
|
|
Medication Added, Changed, deleted Yes / No
|
|
|
recommendations for health maintenance
• • •
|
|
|
limitation or restrictions for activities including work, lifting, standing, and bending
|
|
|
does this person use adaptive equipment?
|
|
|
change in health status from previous year Yes / No
|
|
|
specialist consult recommended Yes / No
|
|
|
seizure disorder present Yes / No
|
date of last seizure
|
|
name of the medical provider who completed the annual physical
• • •
|
|
