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Chief Complaint
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Chief complaint- Patient's words
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Chief Complaint
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Chief Complaint- Extra notes
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Chief Complaint-MY WORDS
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Intermittent or Constant
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Pain severity (1-10-10/10)
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Improving Factors
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Onset of present condition
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Past Medical History
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Exacerbation Factors
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PMH-OTHER- NOT LISTED
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PMH
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Prior Treatment
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Family History
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Other Vaccines- NOT LISTED
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Immunizations/Vaccines
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Review of Systems
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ROS Head and Eyes
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ROS Ears, Nose and throat
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ROS Respiratory
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History of Present Illness
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Symptoms Getting Better
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Pt point to show pain location
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Duration (present for the past___)
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Foot Pain
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Foot Pain Areas Comments
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Foot Pain Areas
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Ankle Pain
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Ankle Pain Areas
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Ankle Pain Area Comments
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Exams
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Dermatologic Exam
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Dermatologic Exam normal
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Deformities//Nail malformations
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Explanation of the Deformities (if any)
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Neurological Exam
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Neurological Exam- Abnormal
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Neurological Exam- other notes
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Musculoskeletal Exam
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Musculoskeletal Exam- Abnormalties
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Exam Musculoskeletal (Results)
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Musculoskeletal exam- extra notes.
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Vascular Exam
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Dorsi Pedis right foot
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Dorsi Pedis left foot
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Posterior tibial-right foot
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Posterior Tibial-left foot
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Capillary refill time-right foot
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Capillary refill- left foot
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On if Edema is present.
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No Edema
• • •
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Pitting Edema- left foot
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Pitting Edema- right foot
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Assessment
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Assessment
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Treatment
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Treatment
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Debridement of Nails
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Foot Joint injection Areas
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Foot Injection mixture
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Ankle Injection site-click whole sentence,2parts
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Ankle Injection mixture
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Treatment Extra notes
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Compliant
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Non-Compliant
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Plan
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Plan- Patient advised to:
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Clinical Photo
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Signature
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Signature
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R/A
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