History and Physical Maker for Paper, EHR or USB

History and Physical Form

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Create a history and physical document, then store it on a USB key chain drive or print it out to present to healthcare professionals.

Joe

Original Start Date: October 2, 2005

H and P Form will create an admission note for an initial patient encounter. It's supposed to be used for a history and physical. The idea is to add more fields so they can be used as individual data points for research later.

I'd appreciate any comments or suggestions.

Thanks,
Joe

Table Properties

Width (%): Border:

Text Properties

Header Properties

Weight: Color: Background Color:

Text Properties

Weight: Color: Background Color:

Description

CC:

HPI:

Past Medical History:

Past Surgical History:

Medications

Immunizations

Allergies

Family History

Social History

Review of Systems

General: () weight loss () fever () night sweats () weakness/fatigue () appetite Endocrine: () heat intolerance () decreased energy () thyroid/reanl dz () polydipsia () polyuria Lympatics: () lymphadenopathy Skin: () itching () pale () palmar creases Hematology: () anemia () bruising () bleeding Head: () seizures () trauma () loss of conscioussness () headache () vertigo () dizziness Eyes: () visual changes () blurred vision () loss of vision () discharge Ears: () discharge () ear pain () tinnitus () ototoxic drug history () hearing loss Nose: () discharge () rhinorrhea () epistaxis Mouth and Throat: () lip cracking () gum soreness () gum hypertrophy () dryness () thirst () excessive salivation () throat pain () hoarseness Cardiorespiratory: () SOB () valvular disease () orthopnea () dyspnea on exertion () nocturia () edema () paroxysmal nocturnal dyspnea () cough () cyanosis () hemoptysis Gastrointestinal () dysphagia () abdominal pain () vomiting () hematemesis () melena () hematochezia () change in appetite () diarrhea () constipation () jaundice Genitourinary: () change in bladder function () change in amount () dysuria () hematuria () discharge Neuropsychiatric: () weakness () motor/sensory deficit () depression () anxiety Pain:

Physical Exam

General Appearance: Vital Signs: Temperature: Oxygen Saturation: Blood Pressure: Respiratory Rate: Pulse Rate: Skin/Nails: Head: Eyes: Ears: Nose: Throat/Mouth: Neck: Lymph: Pulmonary: CV: Abdomen: Breasts: Rectal: Genitals: Peripheral pulses: Musculoskeletal: Neurologic: Mental Status CN I CN II CN III,IV, VI CN V, VII CN VII CN VIII CN IX, X CN XI CN XII Cerebellar DTRs

Labs

Chem 8

Na:	Cl:	BUN:	Glucose:
K:	CO2:	Cr:	Ca:

CBC

WBC:

Hgb:
Hct:

Plt:
MCV:

Coags

PT: PTT:
INR:

Assessment/Plan

Final:

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