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    H&P Sheet

    Uploaded by

    Mark Ma
    This document contains sections for collecting a patient's personal and medical history, including their name, date of birth, age, history of present illness, past medical history, past surgical history, current medications, allergies, family history, social history, review of systems, vital signs, and physical exam findings. The review of systems and physical exam sections include checkboxes to indicate symptoms or exam findings for various body systems.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    H&P Sheet

    Uploaded by

    Mark Ma
    152 views1 page
    This document contains sections for collecting a patient's personal and medical history, including their name, date of birth, age, history of present illness, past medical history, past surgical history, current medications, allergies, family history, social history, review of systems, vital signs, and physical exam findings. The review of systems and physical exam sections include checkboxes to indicate symptoms or exam findings for various body systems.

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    H&P

    Original Title

    h&p sheet

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    This document contains sections for collecting a patient's personal and medical history, including their name, date of birth, age, history of present illness, past medical history, past surgical history, current medications, allergies, family history, social history, review of systems, vital signs, and physical exam findings. The review of systems and physical exam sections include checkboxes to indicate symptoms or exam findings for various body systems.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    152 views1 page

    H&P Sheet

    Uploaded by

    Mark Ma
    This document contains sections for collecting a patient's personal and medical history, including their name, date of birth, age, history of present illness, past medical history, past surgical history, current medications, allergies, family history, social history, review of systems, vital signs, and physical exam findings. The review of systems and physical exam sections include checkboxes to indicate symptoms or exam findings for various body systems.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    Name/DOB/Age:

    HPI (O L D C A R T S):

    PMH (with years):

    PSH (complications):

    Meds (dose, regimen):

    Allergies (with reaction):


    FH (parents, siblings, extended family):

    SH:
    Living:
    Tob/Alc/Drugs:
    Job/Education:
    Sex/STDs/IPV:
    Diet:
    Exercise:
    Stress/Support:
    ROS:
    Gen: fever chills appetite/weight change headache
    Skin: rashes sores moles itches
    Eyes: pain vision loss blurriness double vision
    Ears: pain hearing loss ringing
    Nose: change in smell sinus pain congestion
    Throat: sores sore throat hoarseness
    Pulm: cough sputum wheezing pain sleep probs
    Card: chest discomfort SOB PND orthopnea
    palpitations edema lightheaded fainting
    GI: abd pain diarrhea constipation heartburn blood
    GU: freq urge pain blood stream incontinence
    Gyn: abn menses dyspareunia discharge sores
    MSK: myalgia arthralgia cramps stiff
    Vasc: claudication varicose veins telangiectasias
    Neuro: weak numb tingling paralysis memory loss
    Heme: bruising bleeding petechiae
    Endocrine: cold/heat intol polydipsia polyuria
    Psych: mood swings depressed worry interest
    PE (strike means abnormal):
    Vitals: Temp
    HR
    RR
    BP
    Gen: NAD, well groomed, description
    Skin: Warm, dry, well-perfused. No rashes or ulcers.
    HEENT: PERRLA, EOMI, moist membranes, anicteric
    Neck: no palpable nodes in _ chains, thyroid nonpalpable
    Lungs: sym excursion, auscultation, percussion, fremitus
    Card: S1 S2 normal, no murmurs/rubs, no thrills, JVD
    absent, no edema, pulses present
    Abd: sounds, nontender, liver nl, spleen nl, no bruits
    MSK: knees, shoulders, ROM, no tenderness
    Neuro: A&Ox3, all strength 5/5, finger-nose nl, romberg,
    sensation, reflexes nl, CNs intact, normal gait
    Psych: Affect

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