Patient name:_________________________________________________________________DOB:____________________________________________________________________________Chief complaint: _____________________________________________________________Medical hx_____________________________________________________________________Meds____________________________________________________________________________Surgeries_______________________________________________________________________Social hx________________________________________________________________________Allergies________________________________________________________________________Vaccine status_________________________________________________________________

SUBJECTIVE

1. GENERAL_________________________________________________________________________

2. HEENT____________________________________________________________________________

3. CARDIOVASCULAR______________________________________________________________

4. RESPIRATORY____________________________________________________________________

5. GASTROINTESTINAL____________________________________________________________

6. PERIPHERAL VASCULAR________________________________________________________

7. GENITOURINARY_________________________________________________________________

8. MUSCULOSKELETAL_____________________________________________________________

9. INTEGUMENT_____________________________________________________________________

10. NEURO_____________________________________________________________________________

11. PSYCHE____________________________________________________________________________

OBJECTIVE

LABS/DIAGNOSTIC TESTS

1. CBC_________________________________________________________________________________

2. CMP________________________________________________________________________________

3. UA__________________________________________________________________________________

4. X-RAY______________________________________________________________________________

5. _____________________________________________________________________________________

6. _____________________________________________________________________________________

7. _____________________________________________________________________________________

PHYSICAL EXAM

1. GENERAL_________________________________________________________________________

2. HEENT____________________________________________________________________________

3. CARDIOVASCULAR______________________________________________________________

4. RESPIRATORY____________________________________________________________________

5. GASTROINTESTINAL____________________________________________________________

6. PERIPHERAL VASCULAR________________________________________________________

7. GENITOURINARY_________________________________________________________________

8. MUSCULOSKELETAL_____________________________________________________________

9. INTEGUMENT_____________________________________________________________________

10. NEURO_____________________________________________________________________________

11. PSYCHE____________________________________________________________________________

ASSESSMENT

1. ______________________________________________________________________________________________

2._______________________________________________________________________________________________

3._______________________________________________________________________________________________

4. ______________________________________________________________________________________________

5._______________________________________________________________________________________________

6. ______________________________________________________________________________________________

PLAN

1. ______________________________________________________________________________________________

2._______________________________________________________________________________________________

3._______________________________________________________________________________________________

4. ______________________________________________________________________________________________

5._______________________________________________________________________________________________

6. ______________________________________________________________________________________________