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Initial Physical Examination
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General Information
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Name
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Date
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Chief Complaint
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MRN#
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HPI
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Occupation
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Martial Status
• • •
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Physical Exam
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HT
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WT
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HR
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BP
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TEMP
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Current Meds
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List on current meds
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List on current meds
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List on current meds
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List on current meds
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List on current meds
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Allergies
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list of known allergies
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list of known allergies
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list of known allergies
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list of known allergies
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list of known allergies
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Family History
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Relative
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Illness
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Mother
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Illness
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Father
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Illness
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Maternal Grandfather
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Illness
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Maternal Grandmother
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Illness
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Parental Grandfather
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Illness
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Parental Grandmother
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Illness
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Other...
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Illness
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Social
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Status
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Smoker
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Status
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Alcohol
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Status
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IDVA
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Status
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Obstetrical
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#
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GRAVA
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#
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PARA
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#
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ABORT
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#
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Other
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#
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Gynecological
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REG. PERIODS
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Yes / No
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DATE OF LAST
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LMP
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MAMMOGRAPHY
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SELF BREAT
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PAP
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REVIEW OF SYSTEM
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SPECIFY
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HEENT
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RESP
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C-V
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G.L.
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G.U/GYN
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NEURO
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ENDO
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PSYCH
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SKIN
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MUSC. SKEL
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GENERAL APPEAR
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HEENT
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LUNGS
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HEART
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ABDOM
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G.U/GYN
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EXT
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NEURO
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SKIN
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LAB
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IMPRESSION
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NOTES
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RX:
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FOLLOW-UP INTRACTIONS GIVEN TO PATIENT
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