Professional Documents
Culture Documents
PT NAME
BILL#
MR#
DOB
DOA
Chief Complaint:
Time________________
Activity_______________
ALLERGIES____________________
1) ____________________ _______
_______________
2) ____________________ _______
______________
3) ____________________ _______
______________
4) ____________________ _______
______________
5) ____________________ _______
______________
ECHO (
/
)
_____________________________
STRESS (
/
)
_____________________________
CATH (
/
)
SOCIALLiving
_____________________________
Functional
- ADLs
CABG (
/
)
_____________________________
Work
Spiritual
EGD (
/
)
Emotional
_____________________________
Tob (
)_______pk/day x
________
FLU:yrs
Y/N
PNA: Y / N
PCP______________________
PULM____________________
CARDS____________________
NEURO____________________
NEPHRO___________________
Onset__________________
Location_______________
___
Duration______________
____
Character_____________
_____
Aggravate____________
______
Alleviate______________
____
Radiation_____________
_____
Past
Past
Med Hx
Surg Hx
1)
1)
2)
2)
3)
3)
4)
4)
5)
5)
6)
6)_________________
CODE STATUS:
GENERAL: Weight , fatigue, weakness,
fevers, chills,MOM
night sweats.
DAD
EYES: vision
EARS: hearing changes,
tinnitus, vertigo, earache
NOSE/SINUSES: rhinorrhea, coryza,
congestion, sneezing
MOUTH/THROAT/NECK: hoarseness, sore
throat or dental concern
CV: angina, palpitations, dyspnea on
exertion, orthopnea, PND, edema
RESP: SOB, wheezing, coughing w/wo
sputum, hemoptysis
GI: anorexia, dysphagia, indigestion,
abdominal pain, n/v/c/d,
melena, hematochezia, hematemesis or
changes in bowel patterns