Diagnostic Reasoning and Advanced Physical Assessment
Diagnostic Reasoning and Advanced Physical Assessment
Comprehensive History & Physical Exam
DEMOGRAPHICS
Providers Name: ___________________________________ Patient’s Initials: (Data Source)____________________
Date of Exam: _______________________________________________________ Patient’s DOB: _______________
Chief Complaint: Gender/Sexual Orientation: ____________________
History of Present Illness:
Past Medical History:
Active Problems:
Resolved Problems:
Previous Hospitalizations:
Surgical History:
Allergies:
Current Medications:
Social History:
Living Arrangements:
Occupation:
Environmental Safety:
Smoking:
Alcohol:
Drugs:
Other Non-Prescribed Drugs:
Diet:
Family History:
Relationship
Living or Deceased
Age
Illnesses
Mother
Father
Children
Grandparents
Preventative Health/ Anticipatory Guidance: (Age Appropriate)
Safety Issues:
Screenings:
Immunizations:
Review of Systems:
General:
Skin, Hair, Nails:
HEENT:
Neck:
Cardiovascular:
Pulmonary:
Abd/GI:
Genitourinary/ Gynecology/ Breast
Musculoskeletal:
Neuro:
Endo/Lymphatic:
Hematology:
Psych:
Physical Exam
Patient’s Initials: ________ Date of Exam: _________
Vital Signs: Temp: Pulse: BP: Resp:
General Appearance:
Skin:
Head/Face:
Ears:
Eyes:
Nose:
Mouth/Throat:
Neck:
Heart:
Lungs:
Abdomen:
Musculoskeletal:
Sensory:
Motor:
Peripheral Vascular:
Neuro:
Cranial Nerves:
Reflexes:
Cognitive Function:
Problem Presentation/Assessment Statement: (Summary of presenting problems)
Assessment: Problem List (As many or as few as needed)
1)
2)
3)
Plan:
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