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Date of Last Physical Exam
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Social Security No.
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Chief Complaint
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HISTORY OF PRESENT ILLNESS
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Location of the problem
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How long does the problem last?
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What number best describes the problem?
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When did you first notice the problem?
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Is anything else occurring at the same time?
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Does anything help or make the problem worse?
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Is the problem constant or variable?
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Problem interferes with normal functions?
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If yes, explain
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Notes
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PAST MEDICAL & SOCIAL HISTORY
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List all serious illnesses in your family
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List the date of personal illness/surgery
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Corresponding illness/surgery
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List the date of personal illness/surgery
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Corresponding illness/surgery
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List the date of personal illness/surgery
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Corresponding illness/surgery
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Do you smoke?
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If yes, how much?
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For how long?
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Do you drink?
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If yes, how much?
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Are you on any medications?
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If yes, please list
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Notes
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REVIEW OF SYSTEMS
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Do you now have or had problems related to:
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Constitutional Symptoms
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Fever
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Chills
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Headache
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Other
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Do you now have or had problems related to:
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Eyes
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Blurred Vision
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Double Vision
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Pain
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Other
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Do you now have or had problems related to:
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Allergic/Immunologic
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Hay Fever
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Drug Allergies
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Other
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Do you now have or had problems related to:
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Neurological
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Tremors
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Dizzy smells
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Numbness/Tingling
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Other
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Do you now have or had problems related to:
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Endocrine
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Excessive Thirst
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Too hot/cold
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Tired/Sluggish
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Other
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Do you now have or had problems related to:
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Gastrointestinal
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Abdominal pain
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Nausea/vomiting
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Indigestion/heartburn
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Other
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Do you now have or had problems related to:
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Cardiovascular
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Chest pain
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Varicose veins
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High blood pressure
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Other
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Do you now have or had problems related to:
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Integumentary
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Skin rash
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Boils
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Persistent itch
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Other
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Do you now have or had problems related to:
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Muskuloskeletal
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Joint pain
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Neck pain
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Back pain
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Other
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Do you now have or had problems related to:
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Ear/Nose/Throat/Mouth
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Ear infection
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Sore throat
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Sinus problems
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Other
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Do you now have or had problems related to:
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Genitourinary
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Urine retention
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Painful urination
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Urinary Frequency
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Other
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Do you now have or had problems related to:
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Respiratory
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Wheezing
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Frequent Cough
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Shortness of breath
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Other
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Do you now have or had problems related to:
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Hematologic/Lymphatic
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Swollen glands
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Blood clotting problems
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Other
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Do you now have or had problems related to:
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Psychologic
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Are you generally satisfied with your life?
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Do you feel severely depressed?
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Have you considered suicide?
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Other
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Notes
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GENERAL MULTI-SYSTEM EXAMINATION
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Constitutional
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Vital Signs (Select any 3)
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BP (sitting)
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BP (supine)
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T
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P
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R
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HT
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WT
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General Appearance
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General Appearance (Normal)
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Development
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Nutrition
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Deformities
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Grooming
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Neurologic
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Cranial Nerves
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Cranial Nerves (No Abnormalities)
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Check 2-12
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Only report deficits
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Other
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Reflexes
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Reflexes (No Abnormalities)
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Deep tendon
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Babinski
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Other
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Sensation
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Sensation (No Abnormalities)
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Touch
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Pain
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Other
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Psychiatric
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Judgement
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Judgement (Normal)
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Logic
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Reasoning
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Perception
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Other
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Orientation
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Orientation (Normal)
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Person
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Place
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Time
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Other
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Memory
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Memory (Normal)
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Recent
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Long Term
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Other
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Mood/Affect
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Mood/Affect (Normal)
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Depression
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Anxious
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Other
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Skin
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Inspection
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Inspection (No Abnormalities)
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Jaundice
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Cyanosis
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Lesions
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Rashes
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Palpation
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Palpation (No Abnormalities)
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Turgor
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Induration
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Nodules
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Eyes
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Conjunctiva or Lids
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Conjunctiva or Lids (No Abnormalities)
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Inflammation
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Edema
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Jaundice
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Pupils or Irises
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Pupils or Irises (No Abnormalities)
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Size
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Symmetry
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Reaction
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Opthalmoscopic
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Opthalmoscopic (No Abnormalities)
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Vessels
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Exudate
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Hemorrhage
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Risk
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Ears, Nose, Mouth, Throat
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External Inspection
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External Inspection (No Abnormalities)
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Head
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Ears
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Nose
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Mouth
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Hearing
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Hearing (No Abnormalities)
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Whisper
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Tuning Fork
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Otoscopic
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Otoscopic (No Abnormalities)
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Canal
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Tympanic
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Nose
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Nose (No Abnormalities)
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Nasal Mucosa
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Septum
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Terbinates
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Mouth
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Mouth (No Abnormalities)
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Lip
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Tongue
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Cheek
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Gums
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Orapharynx
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Orapharynx (No Abnormalities)
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Mucosa
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Palate
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Tonsil
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Salivary Glands
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Neck
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Neck
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Neck (No Abnormalities)
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Masses
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Symmetry
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Trachea
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Thyroid
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Thyroid (No Abnormalities)
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Size
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Tenderness
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Nodules
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Respiratory
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Effort
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Effort (Normal)
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Intercostals
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Accessory
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Abdominal
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Percussion
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Percussion (No Abnormalities)
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Dullness
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Flatness
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Hyperressonance
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Palpitation
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Palpitation (No Abnormalities)
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Fremitis
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Ribs
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Auscultation
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Auscultation (No Abnormalities)
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Rales
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Rhonchi
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Wheezes
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Rubs
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Cardiovascular
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Palpation
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Palpation (No Abnormalities)
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Size
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PMI
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Thrill
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Auscutation
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Auscutation (No Abnormalities)
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Murmurs
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Rhythm
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Other
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Carotid
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Carotid (No Abnormalities)
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Bruit
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Pulse
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Amplitude
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Abdominal Aorta
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Abdominal Aorta (No Abnormalities)
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Bruit
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Anuerysm
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Femoral
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Femoral (No Abnormalities)
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Bruit
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Amplitude
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Pedal
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Pedal (No Abnormalities)
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Bruit
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Amplitude
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Veins
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Veins (No Abnormalities)
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Bruit
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Vericosities
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Chest/Breast
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Inspection
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Inspection (No Abnormalities)
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Symmetry
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Retraction
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Nipple
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Palpation
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Palpation (No Abnormalities)
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Masses
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Tenderness
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Abdominal
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Examination of Abdomen
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Examination of Abdomen (No Abnormalities)
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Masses
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Guarding
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Tenderness
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Examination of Liver, Kidney, Spleen
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Examination of Liver, Kidney, (No Abnormalities)
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Size
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Tenderness
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Masses
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Hernia
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Hernia (Absent)
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Inguinal
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Femoral
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Ventral
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Anus, Perineum or Rectum
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Anus, Perineum or Rectum (No Abnormalities)
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Masses
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Hemorrhoid
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Fissures
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Hemoccult
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Hemoccult (No Abnormalities)
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Negative
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Positive
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Genitourinary (Men)
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Scrotum
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Scrotum (No Abnormalities)
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Testicle
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Epididymides
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Cord
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Penis
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Penis (No Abnormalities)
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Uncircumcised
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Inflammation
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Lesion
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Discharge
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Prostrate
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Prostrate (No Abnormalities)
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Symmetry
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Nodule
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Tenderness
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Genitourinary (Female)
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External Genitalia or Vagina
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External Genitalia or Vagina (No Abnormalities)
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Appearance
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Discharge
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Support
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Urethra
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Urethra (No Abnormalities)
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Tenderness
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Masses
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Scarring
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Bladder
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Bladder (No Abnormalities)
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Tenderness
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Masses
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Cystocele
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Rectocele
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Cervix
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Cervix (No Abnormalities)
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Discharge
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Lesion
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Uterus
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Uterus (No Abnormalities)
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Size
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Support
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Masses
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Adnexa/Parametria
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Adnexa/Parametria (No Abnormalities)
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Masses
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Tenderness
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Size
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Lymphatic
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Palpation
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Palpation (No Abnormalities)
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Two (2) or more
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Neck : Size
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Neck : Tenderness
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Axillae : Size
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Axillae : Tenderness
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Groin : Size
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Groin : Tenderness
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Other : Size
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Tenderness
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Musculoskeletal
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Gait or Posture
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Gait or Posture (No Abnormalities)
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Posture
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Shuffle
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Unstable
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Digits
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Digits (No Abnormalities)
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Clubbing
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Color
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Infection
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Joints, Bone, Muscle
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Inspection
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Inspection (No Abnormalities)
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Asymmetry
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Effusions
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Tenderness
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Range of Motion
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Range of Motion (No Abnormalities)
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Crepitus
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Contracture
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Pain
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Stability
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Stability (No Abnormalities)
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Dislocation
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Subluxation
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Laxity
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Strength or Tone
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Strength or Tone (No Abnormalities)
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Flaccid
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Spastic
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Atrophy
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