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Patient Gender Age Doctor

Diagnosis

Diet:

Lab:

Activity:

Treatments:

IV Orders:

MEDICATION ORDERS: ALLERGIES:

Diabetes: Type I Insuin: Type II !edication:

"ood sugar ########## "ood sugar ########## "ood sugar##########

!edication$dose$route$%re&uency reason %or giving Time's( to give

)*

+*

,*

-*

.*

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0*

1*

2*

CHIEF COMPLAINT/PRESENT ILLNESS'34y t4e patient is 4ere(

HISTORY'past iness5 in6uries5 4ospitai7ations5 surgery5 seep patterns5 %amiy(

GENERAL: 8orma 9eig4t ##### "$P####### Puse##### Respirations###### Temperature#####

SKIN'ras4es5 itc4ing5 4ives5 bruising5 ec7ema5 dryness5 sin coor c4anges5 4air te;turec4anges5 nai te;ture c4anges5 appearance o% nais 'incuding toes(5 previous sin disorders5umps5 use o% 4air dyes(

EYES, NOSE, EARS'eyegasses5 redness5 probems 3it4 vision5 eye disc4arge5 gaucoma5cataracts5 ast eye e;am5 eye in6uries5 nasa disc4arge5 nosebeeds5 sinus in%ections5 4ay %ever5nasa obstruction5 %re&uency o% cods5 4earing aid5 4ard o% 4earing5 dea%ness5 ringing in ears5di77iness5 ear disc4arge5 pain in ears(

PERRLA#####

MOUTH AND THROAT'condition o% teet4 and gums5 bad breat45 probems 3it4 c4e3ingor eating5 ast denta e;am5 %re&uency o% sore t4roats5 c4anges in voice5 persistent 4oarseness5

t4yroid probems5 goiter5 umps5 pain in nec5 s3oen gands(

BREAST'umps5 disc4arge5 pain5 %re&uency o% se% e;am(

CARDIOVASCULAR'c4est pain5 papitations5 murmurs5 4ig4 bood pressure5 s4ortness o%breat4 3it4 e;ertion or ying do3n5 4istory o% 4eart attac or r4eumatic %ever5 varicose veins5pain in egs or caves 3it4 3aing5 s3eing in egs or %eet5 cooness o% an e;tremity5 oss o% 4airon egs5 discooration o% an e;tremity5 ucers(

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