NORTHERN VIRGINIA COMMUNITY COLLEGE

PATIENT HISTORY AND PHYSICAL EXAM REPORT

EMERGENCY MEDICAL TECHNICIAN PROGRAM
Date: __________ Time: ___________ Sex: M F Age: ____ Weight: _____ Race: _______________
Occupation: ________________________________

Military: Yes No Out of country: Yes No

Chief Complaint: _______________________________________________________________________

O(Onset): _____________________________________________________________________________
P(Provocation): _________________________________________________________________________
Q(Quality): ____________________________________________________________________________
R(Radiation): __________________________________________________________________________
S(Severity): ____________________________________________________________________________
T(Time): ______________________________________________________________________________
AS(Assoc. Symptoms): ___________________________________________________________________
PN(Pertinent Negatives): _________________________________________________________________
Known Allergies: NKA __________________________________________________________________
Past Medical History/Family History
Gen. Health:
Childhood:
Adult:

Excellent
Measles
Diabetes
Seizures
MI/other

P =patient; F =family

Good
Satisfactory Fair Poor
Mumps Rubella
Chickenpox
Meningitis Rheumatic
COPD Cancer Pneumonia Ulcers
Hypertension
CVA/Stroke TB Asthma Coronary Disease Coronary Bypass
Psychiatric Kidney Weight + - Arthritis Alcoholism

Other: _________________________________________________________________________________________
Current Meds: ___________________________________________________________________________________
_______________________________________________________________________________________________
Accidents/Injuries: ________________________________________________________________________________
Surgeries: _______________________________________________________________________________________
Home Situation:
Marital Status _________________
No. of Children___________
Religious Limitations to Medical Care:
None
Substance Use: Tobacco __________ pk/yr Alcohol __________ drink/wk Other ___________________________
Dietary Restrictions/Practices: _______________________________________________________________________
Sleep:
Regular Irregular Light / Medium / Heavy ___________________ Hours/eve: _______________________
Exercise: None
Type ________________________
Hours/wk: __________________ ____________
Screening Test: Prostate
Colon
Mammogram
BoneDen
Blood
Urine
X-ray
CAT
Immunization: Tetanus
Hepatitis B
Chickenpox
MMR
Polio
Flu

Review Systems
HHEENT
None Headaches / Migraines
Eyes: None Cataracts Diplopia Blurred Vision Decreased Activity Glaucoma
Ears/Hearing:
None Loss L / R Tinnitus L / R
Vertigo Discharge L / R
Nose: None Epistaxis
Sinusitis
Throat: None
Soreness
Sleep Apnea
Mouth: None
Ulcers
Tooth Loss
Bleeding
Receding Gums
Pulmonary: None Cough Wheezing Chronic infections Emphysema
Cardiac: None Pain/Pressure Murmur
SOB Edema
MVP
Pacemaker CHF
GI: None
Weight Gain / Loss
Nausea
Emesis
Diarrhea Hemorrhoids/Bleeding
GU: None
UTI
Hematuria
Polyria
Kidney stone
Neurological:
None Dizziness
Seizure s Syncope
Weakness/Numbness
Hematological: None Easy bruising Anemia
Blood transfusions
Endocrine: None Polyuria
Polydipsia
Polyphagia
Cold/Heat Intolerant
Fatigue
Vascular: None
Phlebitis DVT
Variocosities
Leg cramps
Musculoskeletal: None Back pain
Fractures
Sprains Deformities
Dermatological: None Rash/Uticaria Dryness Pigment changes Mole changes
Edema
Psychological:
None
Depression
Panic attacks
Memory loss
Attitude:
Positive
Negative
Unsure

Physical Exam
General Appearance:
Distress
Well/Malnourished
Vital Signs:
Temperature: ________ Pulse: ________ Respiration: ________ BP: _______
HEENT
Face WNL
Symmetrical
Droop Left / Right
Eyes WNL
PEERLA
Sclera White/Yellow/Red
H test Normal_______________
Ears WNL
Partial Loss L / R Complete loss L / R
Discharge L / R
Nose WNL
Discharge
Discoloration
Throat WNL Swollen
Tender
Uvula Midline Tongue Midline
Carotid 0 1+ 2+ 3+
Neck WNL
JVD
Trachea Midline Nodes Palpable Swallow: Normal Painful Difficult
Shrugs Equal Weakness Left/Right_______________________________________________________
Pulmonary
O2 at ________ 1/min via NC/NRB Shallow/Deep/Labored/Accessory muscles
Sounds
Left ____________________________Right___________________________________
Cardiac
S1S2 (lubdub) ________________ Murmur Regular/Irregular _____________________
Abdomen
Soft
Tender
Distended Guarded Rebound
Nausea/Emesis
Sounds
Normal Hyperactive
Hypoactive
Absent___________________________
Muscloskeletal Tone Excellent Good Poor Atrophy__________________________________
Moves all extremities
Weakness Left/Right
Flaccid Left/Right
Spine
Normal/good
Lordosis
Kyphosis
Scoliosis
Pulses
L Radial/Ulnar 0 1+ 2+ 3+
Dorsalis Pedis 0 1+ 2+ 3+
Posterior Tibia 0 1+ 2+ 3+
R Radial/Ulnar 0 1+ 2+ 3+
Dorsalis Pedis 0 1+ 2+ 3+
Posterior Tibia 0 1+ 2+ 3+
Skin Deformities ________________________________________________________________________
Cap refill <2 Edema _________ Abrasions _________ Ecchymosis _________ Cyanosis ____________
Cranial Nerves All OK
II, III PEERLA
III, IV, VI Extra-ocular muscles intact
V
Clenches teeth sensation intact
VII
Muscles of facial expression symmetrical
VIII
Hearing intact
IX, X Gag reflex intact, uvula midline
XI
Shrugs shoulders
XII
Tongue protrudes midline
Glasgow Coma Score: _____ Eye Opening 4 3 2 1
Speech 5 4 3 2 1
Motor 6 5 4 3 2 1
Problem List/Impression:
Plan/Patient Management: