Practice Name

Name: Ins: Age: DOB: Date

Wt: lbs Ht: BMI LMP:

Temp: BP: / HR: RR: SpO2 VS Reviewed 
CC: MA / Nurse:
Allergies:

Medications Reviewed 
HPI Reviewed and Unchanged R ROS: Reviewed R Form Reviewed 
PMH:  HEENT: 
Respiratory: 
FH:  CV / Chest: 
GI / Abd: 
SH:  GU: 
Musc. / Skel: 
Skin / Lymph: 
Neuro / Psych: 
Smoking Hx: ppd x yrs
None Pt Household Counseled >3 minutes Precontemplative
Gen Appearance / Mood / Affect / Orientation: WNWD/AAO/NAD Labs / Test / Diagnostic Procedures
HEENT: nml eye movement, conjunctivae & lids, perrl, thyroid, external ears,nose, lips Urine Dip  Holter Monitor
Respiratory: nml rhythm, deep & even, symetrical, BBS clear Rapid Strep  PFT
Heart: S1/S2, w/o murmur, edema, strong/= pulses BUE Influenza  EKG
Abdomen: No masses, tenderness, hernias Urine HCG  Ear Irrigation R / L
Musc/Skel: Nml steady gait, station, overall strength and tone Mono-Spot  Typmanogram
Skin:  p/w/d, free of concerning rashes, bruises, lesions HgA1C  Lipid Panel
Neuro: Nml facial symetry, DTRs, sensation, H. Pylori  Old Records
Lymp: No palpable nodes, cervical, submental, subclavicular Other X-ray
Additional: Neb Tx FS Blood Glucose
Injection _____Toradol ______ Rocephin
Injection
Send out labs
CBC CMP BMP TSH PT/PTT INR
Assessment: Plan:

 Instructed on typical course of illness / injury and potential further workup.  Weight / Exercise / Nutrition Counseling
 Side effects discussed  Diabetic Counseling
 Pt instructed to return if worse or if further symptoms develop ER Instructions given  Discussed age appropriate medication use for
 Information sheets given symptomatic relief

 Discussed  Smoking  Illicit Drugs  ETOH  High Risk Sexual Behavior  Breast Self Exam  Discussed appropriate use of narcotic meds
 Labs / Test Result Reviewed Discussed  Return Appt. in__________ days / wks / month
 Plan Discussed with patient and verbal consent obtained
 Patient (Caregiver) verbalized understanding Date:
 Greater than 50% of minutes spent in counseling /coordinating re: