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REASON FOR VISIT
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HPI/INTERIM HISTORY
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ALLERGIES
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CURRENT MEDICATIONS
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PAST MEDICAL HISTORY
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PAST SURGICAL HISTORY
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SOCIAL HISTORY
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FAMILY HISTORY
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REVIEW OF SYSTEMS
• • •
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VITAL SIGNS
• • •
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PHYSICAL EXAM
• • •
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LABS
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IMAGING/TESTS
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DIAGNOSIS
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ASSESSMENT
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PLAN
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NEW LAB ORDERS
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NEW RADIOLOGY
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INNECTIONS/IMMUNIZATIONS
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NEW MEDICATIONS
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PROCEDURES
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NEW REFERRALS
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COUNSELING
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FOLLOW UP/RETURN TO OFFICE
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TIMING OF FOLLOW UP
• • •
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REASON FOR FOLLOW UP
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REMINDERS
• • •
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