Patient Information Name_________________________

ID Number_____________________

1) Since your last visit to our office, were you admitted to the hospital?
Yes  No 
If yes, please write where and when:_____________________________________________

2) Since your last visit to our office, have you had any medical tests?
Yes  No 
If yes, please check any that apply:
 Mammogram (breast xray)  Pap smear (for women)  Colonoscopy
 Blood work  X-rays  ECG / EKG (heart)
 Vision  DEXA (checks for bone loss, or osteoporosis)
 MRI  CT (“CAT” scan)  other ______________
List where and when you had the tests done_____________________________________

3) Since your last visit to our office, have you developed any new allergies or had a bad
reaction to a medication or food?
Yes  No 
If yes, describe: _____________________________________________________________

4) Since your last visit to our office, have you seen a specialist (such as a doctor for
diabetes, heart, kidneys, cancer, eyes, gynecology, etc.)?
Yes  No 
If yes, who did you see and when?

Name Approx. Date

Name Approx. Date

5) Since your last visit to our office, have you had any vaccinations (shots)?
Yes  No 
If yes, check the shots you received:
 flu  tetanus  pneumonia
 other - please list:__________________________________________________________

6) Since your last visit to our office, have you started any new prescribed medications?
Yes  No 
If yes, list: __________________________________________________________________
___________________________________________________________________________

______________________________________
Your Signature and Today’s Date
 Patients Name: _____________________________________________

Patient Progress and Medications Date of Birth: ______________________________________________

Medical Record Number: ____________________________________

Allergies:  No  Yes (If Yes, See Adult Summary Form)

Problems: (Optional)

Date
Height/Weight
Blood Pressure
Pulse
Temperature/RR
Tobacco: C, F, N/Counseling
(Current, Former, Never) (Y/N)
Fingerstick/HbA1c
Total Chol./LDL/HDL

Medication Dose/Route

Frequency

daily bid tid qid nightly prn

daily bid tid qid nightly prn

daily bid tid qid nightly prn

daily bid tid qid nightly prn

daily bid tid qid nightly prn

daily bid tid qid nightly prn

daily bid tid qid nightly prn

daily bid tid qid nightly prn

daily bid tid qid nightly prn

 Patient Name: ________________________________________
PATIENT HEALTH NOTE Date of Birth: ________________________________________
Date: ____________________________ Medical Record Number: _______________________________
 New  Return  Periodic

 Chart Not Available  Interval ED Visit  Interval Admission Allergies:  Yes (See Adult Summary Form)
 Missed App’t(s)  Needs Prescriptions  No

CC: _________________________________________________________________________________________________________

____________________________________________________________________________ Initial: ___________________________

HPI: (Location, Quality, Severity, Duration, Timing, Context, Modifying Factors, Assoc. Signs/Symptoms)
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________

Medications:  None  See Updated Med List

Review of Systems:
+ - Constitutional + - + - + - Musculoskeletal + -
  Change Wt   Tinnitus   Constipation   Arthritis   Breast Pain
  Fatigue   Ulcers   Diarrhea   Cervical Pain   Breast Lumps
  Temperature/Chills Respiratory   Dysphagia   Decreased Motion   Breast Discharge
  Weakness   Asthma   Fecal Incontinence   Gout Endocrine
Skin   Bronchitis   GERD   Injuries   Heat/Cold Intol.
  Chng Color   Cough   Hematochezia   Joint Pain   Neck Enlargement
  Chng Hair/Nails   DOE   Hemorrhoids   Joint Stiffness   Polydipsia
  New Lesions   Hemoptysis   Melena   Locking Joints   Xerosis
  Pruritis   Pneumonia   N/V   Low Back Pain Neurologic
  Rash   SOB   PUD   Swelling   Chng Concentration
  Xerosis Cardiovascular + - Genitourinary Psychiatric   Chng Memory
Eyes   Angina   Chng Stream   Depression   Dizziness
  Cataracts   CAD   Hematuria   Homicidal Ideation   Headache
  Chng Vision   Chest Pain   Hernia   Substance Abuse   Imbalance
  Glaucoma   Claudication   Hesitancy   Suicidal Ideation   Numbness
  Redness   DOE   Impotence   Time/Place Orientation   Seizures
ENMT   Edema   Incontinence   Recent/Remote Memory   Tremor
  Bleeding Gums   HTN   Nocturia   Anxiety/Agitation   Weakness
  Chng Hearing   Orthopnea   Polyuria Female Reprod. Hematologic
  Chng Voice   Palpitations   Scrotal Masses/Pain   Abnormal Menses   Anemia
  Dentures   PND   STD’s   Dryness   Easy Bruisability
  Epistaxis Gastrointestinal   Urgency   Dyspareunia   Enlarged LN’s
  Hoarseness   BRBPR   Sexual Abuse   HxTransfusions
  Sinusitis   Chng Bowel Habits   Vaginal Discharge

Comments:
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
 PMH Reviewed – No Changes; See Adult Summary Form  PMH Reviewed & Updated; See Adult Summary Form
 SHx Reviewed – No Changes; See Extended Hx Form  SHx Reviewed & Updated; See Extended Hx Form
 FHx Reviewed – No Changes; See Extended Hx Form  FHx Reviewed & Updated; See Extended Hx Form
Vital Signs: Age: ____________
Weight: ____________BMI: _____________Temperature: _____________Blood Pressure: ______________Pulse: _______________

Respirations: ________ Fingerstick: _____________ LMP: _____________ Oxygen Saturation: _______________ Initials: _________

Physical Exam:
Nl Ab General Nl Ab Nl Ab Nl Ab Nl Ab MSK
  Appearance   Auscultation   Bowel Sounds   Axillary   Inspection
  VS   Percussion   Palpation   Inguinal   Exam of Joint
Eyes   Palpation   Liver Span   Other ___________   Head & Neck
  Conjunctiva/lids CV   Spleen Skin   Spine/Ribs
  Pupils (Reactivity/Accom)   PMI   Inguinal Area   Inspection   Pelvis
  Disc/Fundi   Palpation GU – Male   Palpation   RUE Stability
  EOM   Auscultation   Scrotum/Testes Neuro   LUE ROM
ENMT   Rhythm   Penis   Cranial Nerves   RLL Strength
  Ear Infection   Rate   Anus   Tendon Reflexes   LLE
  TMs & Canal   S1   Perineum   Biceps   ROM
  Hearing (Whisper, Etc.)   S2   Rectal Area (Ext.)   Triceps   Gait
  Weber   Carotid Art.   Prostate (DRE)   Patellar   Clubbing/Cyanos
  Rhinne   Abd. Aorta   Occult Blood   Achilles Edema
  Nasal Mucosa/Septum/   Fem. Pulses GU – Female   Brachioradialis Psychiatric
Turb.   Extremities (Edema/   Ext. Genitalia   Motor Strength   Orientation
  Lips/Gums/Teeth Varicose Veins)   Urethra   Upper Ext. – Strength (Person, Place, Time)
  Oropharynx Chest   Cervix   Lower Ext. – Strength   Mental Status
Neck   Inspection   Adnexa   Sensory   Judgment
  Appearance   Palpation   Uterus   Light Touch   Insight
  Symmetry   Right Breast   Bladder   Pin Prick   Short-Term Mem
  Trachea   Left Breast   Saline/KOH   Vibration   Long-Term Mem
  Thyroid   Right Axillae   Rectal Exam   Temperature   Mood
  Lymph Nodes   Left Axillae   Occult Blood   Proprioception   Affect
Lungs Abdomen Lymph Nodes   Romberg   Concentration
  Resp. Effort   Inspection   Neck   RAM   Speech
  Rib Excursion   Supraclavicular   Babinski Eval

Comments: ____________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________

Assessment & Plan: ___________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________

 SF  L  M  H Medical Decision-Making
 See Continuation Sheet
 Counseling  Seat Belts  INR  CXR BP Check In
 Advance Directives  Smoke Detectors  PAP  Echocardiogram ____ Day(s)
 Alcohol  STD/HIV Counseling  Pregnancy Test  Electrocardiogram ____ Week(s)
 BSE  Substance Abuse  PSA  Flex Sig ____ Month(s)
 Dental Care  Sun Protection  Rapid Strep  IVP Call Office
 Diabetes  TSE  Renal Profile  Mammogram ____ Day(s)
 Domestic Violence  Tobacco Cess.  RPR  Stress Echo ____ Week(s)
 Exercise Labs Ordered  Stool Cards  Stress Test ________________ ____ Month(s)
 Eye Protection  BMP  TFTs  Ultrasound ____ Prn
 Foot Care  CBC  Throat Culture  Follow Up ________________ Labs to be Done In
 Firearms Risk  Cholesterol Profile  Urinalysis Follow Up ____ Today
 Hearing Conserv.  CMP  Urine Culture ____ Day(s) ____ Day(s)
 Hormone Replacement  Drug Level  Urine Pregnancy Test ____ Week(s) ____ Week(s)
 Medication S/E  GC/Chlamydia  Other _______________ ____ Month(s) ____ Month(s)
 Noncompliance  Hb A1c Tests Ordered ____ Prn
 Nutrition  Hepatic Profile  BE  Old Records Requested
 Osteoporosis  Hepatitis Serology  Colonoscopy  Pending Test(s) ___________
 Pregnancy Prevention  HIV  CT/MRI _____________

Referred To ________________________________________________________________________ Time Counseling (Minutes) ______________________

Signature __________________________________________________________________________ Date _________________________________________

 Patients Name: ____________________________________

Patient History and Record Date of Birth: _____________________________________

Medical Record #: _________________________________

Primary Care Provider: ________________________________________________________________________

Drug Allergies/Sensitivities: ___________________________________________________________________

Emergency Phone #: _______________________ Contact Person/Relationship: __________________________

ICD
Chronic Medical Problem List Date Past Surgical History Date
Code

Hospitalizations Date

Family History of Initial Risk Assessment Social History

Y N Family Member
  Alzheimer’s Dz ______________ Date  Married  Single  Civil Union
  Breast Ca ______________
  CAD ______________  Alcohol/Drug Use _________  Divorced  Widow(er)
  Cerebrovas. Dz ______________
  Cervical Cancer ______________  STDs _________  Lives Alone  Separated
  Colon CA ______________  Domestic Violence _________
  Depression ______________  Depression _________ Occupation: ______________________
  DM ______________
 Osteoporosis _________
  Fe Storage ______________ Religious Preference: ______________
  Glaucoma ______________  Geriatric Assessment _________
  Hyperchol. ______________  MMSE _________ Advance Directive?  Yes  No
  HTN ______________  ________________ _________ If Yes, Date: _________________
  Ovarian CA ______________
  Prostate CA ______________
  Skin CA ______________ Educ.:  JHS  HS  College
  Thyroid Dz ______________
 Other _________________

Signature: ____________________________________________________________ Date: _________________________