History & Physical Examination

Patient's Name:
Admission Date:  		Age:
ID#:
Room:
Doctor(s):
 

Chief Complaint 
History of Complaint:
Past Medical History:
Past Surgical History:
Medications prior to Admission:

Physical Findings and Review of Systems:

HEENT:

(abbreviations)

 

 

Hair:
   

Use the Ctrl. key & Mouse to make multiple selections:
 

Scalp & Skull:

  Face:

  Nose & Mouth:

  Neck:

 

    Lymphadenopathy:
    Tonsillar
Submental
Submandibular
Deep cerv. chain Occipital		 Post. auricular
Superficial cervical
Post. cervical
Supraclavicular
Preauricular
  Eyes:

  Ears:

 

 

Chest & Respiratory:

 

Rate:

/minute
  (terms)    Rhythm & effort:

   

Use the Ctrl. key & Mouse to make multiple selections:
 

Inspection:

  (terms)    Palpation & Percussion:

  (terms)    Auscultation:  
 
Anterior    Posterior   

Right Upper Lung
Areas 1,2,3:
Right Middle Lung
Areas 4,5:
Right Lower Lung
Areas 8,9:
 




 

Left Upper Lung
Areas 1,2,3:
Areas 4,5,6:
Left Lower Lung
Areas 7,8,9: 



  (terms)    SPECIAL TESTS:

FET:

 seconds
  Smoking: packs per year
     
Breast: Breast mass location:  

                

     


       
     
   

 

 

Vitals Signs:

Temp:

 

 

TMAX:

 
X-ray/CT/MRI

Post-Admission Events:

Surgery:
Current Medications & Feedings:
Infectious Disease:
I/O: cc/cc hrs                   

Input=(IVF)+(IVPB)+(Nutrition)+(Drips)
           cc

Output=(Urine)+(NG)+(Others)
           cc
Ventilation:  

Labs:

Admit Labs Yesterday Today  
2001 2001 2001 Concerns

                 
                       
                 

       
         

                 
                       
                 

       
         

                 
                       
                 

       
         






PT=INR=PTT=

PT=INR=PTT=

PT=INR=PTT=

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