Chief complaint
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Social History
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TOBACCO USE
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ALCOHOL USE
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SOCIAL HISTORY(FREE-TEXT)
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FINANCIAL RESOURCES
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EDUCATION
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PHYSICAL ACTIVITY
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NUTRITION HISTORY
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STRESS
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SOCIAL ISOLATION AND CONNECTION
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EXPOSURE TO VIOLENCE
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GENDER IDENTITY
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SEXUAL ORIENTATION
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PAST MEDICAL HISTORY
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MAJOR EVENTS
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SOCIAL HISTORY
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FAMILY HISTORY
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DIAGNOSIS
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ONSET DATE
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FAMILY HEALTH HISTORY(FREE-TEXT)
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Subjective
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Subjective
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ROS
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Constitutional
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Eyes
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Cardiovascular
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Respiratory
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Gastrointestinal
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Genitourinary
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Musculoskeletal
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Integumentary
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Neurological
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Psychiatric
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Endocrine
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Hematological/Lymphatic
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Allergic/Immunological
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Objective
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General
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Head
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Eyes
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Ears
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Nose
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Throat
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Neck
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Chest
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Heart
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Abdomen
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Extremities
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Peripheral pulses bilaterally
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Musculoskeletal
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NEUROLOGICAL EXAM
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Mental status
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Cranial nerve examination
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Sensory examination
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Motor examination
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Deep tendon reflexes
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Coordination
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Ambulation
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Romberg
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Assessment
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Diagnoses attached to this encounter:
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Plan
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Plan
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