|
Location
• • •
|
Laterality
• • •
|
|
Severity
|
Quality
• • •
|
|
Pain Scale
|
Timing
• • •
|
|
Duration
|
Associated Symptoms
|
|
Modifying Factor
• • •
|
Other Modifying Factors
|
|
Notes
|
|
|
Medical Assistant Notes On Patient
|
|
|
Medical Assistant Notes
|
|
|
Past Medical History
|
|
|
Significant Medical History?
|
Medical History
|
|
Past Surgical History
|
|
|
Previous Surgeries?
|
Previous Surgeries
|
|
Past Hospitalization History
|
|
|
Significant Past Hospitalizations?
|
Hospitalizations / Reason
|
|
History and Physical Part 2
|
|
|
GUT
|
BRAIN
|
|
Energy
|
HPA
|
|
Sleep
|
Thyroid
|
|
CV/Glucose/Insulin
|
Blood Pressure/Heart Rate/Heart Rate Variability
|
|
Liver/Lymph/Kidneys
|
Detox/Metals/Liver
|
|
Hormones
|
|
|
Women
|
|
|
Women
|
PCOS
|
|
Men
|
|
|
Men
|
Erectile Function
|
|
Musculoskeletal
|
|
|
Medications
|
|
|
Medications
|
|
|
Supplement List
|
|
|
Supplement List
|
|
|
Family History
|
|
|
Significant Family History?
|
Family History
|
|
Social History
|
|
|
Occupation
|
Caffeine Use
|
|
Alcohol Consumption
|
Recreational Drugs
|
|
HIV Risk Factors
|
|
|
Smoking Status
|
|
|
Smoking Status
|
|
|
Review Of Systems
|
|
|
Constitutional
|
Eyes
|
|
Ears, Nose, Mouth & Throat
|
Respiratory
|
|
Gastrointestinal
|
Genitourinary
|
|
Musculoskeletal
|
Skin/Breast
|
|
Neurological
|
Psychiatric
|
|
Endocrine
|
Hematologic/Lymphatic
|
|
Allergic/Immunologic
|
|
|
Vitals
|
|
|
Vitals
|
|
|
Physical Exam
|
|
|
Constitutional
|
Head and Face
|
|
Eyes
|
Ears, Nose, Mouth and Throat
|
|
Neck
|
Cardiovascular
|
|
Respiratory
|
Chest (Breasts)
|
|
Gastrointestinal (Abdomen)
|
Genitourinary (MALE)
|
|
Genitourinary (FEMALE)
|
Lymphatics
|
|
Musculoskeletal
|
Extremities
|
|
Skin
|
Neurologic/Psychiatric
|
|
Attachments
|
|
|
Notes
|
|
|
Assessment
|
|
|
Notes
|
|
|
Problem List
|
|
|
Notes
|
|
|
Plan
|
|
|
Plan
|
|
|
Counseling
|
|
|
Prescriptions
|
|
|
Prescriptions
|
|
|
Immunizations
|
|
|
Immunizations
|
|
|
Orders
|
|
|
Orders
|
|
|
Preventive Care
|
|
|
Preventive Care
|
|
|
Educational Resources
|
|
|
Educational Resources
|
|
|
Referrals and PCP
|
|
|
Referrals and PCP
|
|
|
Treatment Summary
|
|
|
Nutrition
|
|
|
Exercise
|
|
|
Mind-Body
|
|
|
Labs and Diagnostics
|
|
|
Notes
|
|
|
Client Information
|
|
|
Name
|
Address
|
|
City
|
State
|
|
Zip Code
|
Mobile Phone
|
|
Work Phone
|
|
