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Subjective
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No significant medical history
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Admits medical history
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Prior Diagnoses?
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Current Medications?
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Prior injuries?
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Prior surgeries?
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PMFSH
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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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Comments
|
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Family History
|
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Father's MH
• • •
|
Comments
|
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Mother's MH
• • •
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Comments
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Social History
|
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Caffeine
|
Comments
|
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Alcohol
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Other substances
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Patient's diet
|
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ROS
|
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General [-]
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General
• • •
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General Comments
|
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Skin [-]
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Skin
• • •
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Skin Comments
|
|
|
HEENT [-]
|
HEENT
• • •
|
|
HEENT Comments
|
|
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Neck [-]
|
Neck
• • •
|
|
Neck Comments
|
|
|
Breasts [-]
|
Breasts
• • •
|
|
Breasts Comments
|
|
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Cardiovascular [-]
|
Cardiovascular
• • •
|
|
CV Comments
|
|
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Respiratory [-]
|
Respiratory
• • •
|
|
Resp Comments
|
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GI [-]
|
GI
• • •
|
|
GI Comments
|
|
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Urinary [-]
|
Urinary
• • •
|
|
Urinary Comments
|
|
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Genital (Male) [-]
|
Genital (Male)
• • •
|
|
Genital (Male) Comments
|
|
|
Genital (Female) [-]
|
Genital (Female)
• • •
|
|
Genital (Female) Comments
|
|
|
MSK [-]
|
MSK
• • •
|
|
MSK Comments
|
|
|
Neurological [-]
|
Neurological
• • •
|
|
Neuro Comments
|
|
|
Endocrine [-]
|
Endocrine
• • •
|
|
Endo Comments
|
|
|
Psychiatric [-]
|
Psychiatric
• • •
|
|
Psychiatric Comments
|
|
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Objective
|
Vitals
|
|
InBody %BF
|
|
|
Hearing
|
Left Ear
|
|
Left ear 500hz
|
Left ear 1000hz
|
|
Left ear 2000hz
|
Left ear 3000hz
|
|
Left ear 4000hz
|
Left ear 6000hz
|
|
Right Ear
|
Right ear 500hz
|
|
Right ear 1000hz
|
Right ear 2000hz
|
|
Right ear 3000hz
|
Right ear 4000hz
|
|
Right ear 6000hz
|
|
|
Vision
|
|
|
Far Visual Acuity
/
|
Near Visual Acuity
/
|
|
Color cards missed (0 is not colorblind!)
/
|
Peripheral Fields Intact?
|
|
Peripheral field comments
|
|
|
PFTs
|
|
|
FVC
|
FVC % Predicted
|
|
FVC Comments
|
|
|
FEV1
|
FEV1 % Predicted
|
|
FEV1 comments
|
|
|
FEV1/FVC
|
FEV1/FVC % Predicted
|
|
FEV1/FVC Comments
|
|
|
CPET
|
|
|
VO2 Max
|
VO2 Max % Predicted
|
|
Watts
|
Watts % Predicted
|
|
Time to AT
|
|
|
ACSM Category
• • •
|
|
|
Physical Exam
|
|
|
General WNL
|
General Abnormal
• • •
|
|
General Comments
|
|
|
HEENT WNL
|
HEENT Abnormal
• • •
|
|
HEENT Comments
|
|
|
Neck WNL
|
Neck Abnormal
• • •
|
|
Neck Comments
|
|
|
Cardiovascular WNL
|
Cardiovascular Abnormal
• • •
|
|
Cardiovascular Comments
|
|
|
Lungs WNL
|
Lungs Abnormal
• • •
|
|
Lungs Comments
|
|
|
Abdomen WNL
|
Abdomen Abnormal
• • •
|
|
Abdomen Comments
|
|
|
MSK WNL
|
MSK Abnormal
• • •
|
|
MSK Comments
|
|
|
Neuro WNL
|
Neuro Abnormal
• • •
|
|
Neuro Comments
|
|
|
Extremities WNL
|
Extrem Abnormal
• • •
|
|
Extrem Comments
|
|
|
Skin WNL
|
Skin Comments
|
|
GU WNL
|
GU Abnormal
• • •
|
|
GU comments
|
|
|
Assessment
|
|
|
ALL NORMAL
|
Additional normal comments
|
|
Abnormal
|
|
|
Dyslipidemia
|
Dyslipidemia values
|
|
Glucose
|
Glucose or A1C values
|
|
Liver Enzymes
|
Liver Enzyme Values
|
|
Inflammatory Markers
|
Inflammatory values
|
|
Urine Drug Screen NEGATIVE
|
Urine Drug Screen Positive
|
|
Urine Drug Screen Positive
• • •
|
UDS Positive Comments
|
|
Additional abnormal lab comments
|
|
|
CPET Normal
|
|
|
CPET Abnormal
|
Abnormal CPET Comments
|
|
Radiology Normal
|
|
|
Radiology Abnormal
|
Abnormal Rads Comments
|
|
HPA Normal
|
|
|
HPA Abnormal
|
HPA Symptoms
• • •
|
|
Additional comments
|
|
|
Plan
|
Statement of Work
|
|
Restriction Comments
|
Stratification
|
|
Action Plan
|
Due Date
|
|
NFPA Chapter/section
|
Action plan comments
|
