Date: e
Patient Demographics and Vital Signs
Patient initials Height 5'8"
Age 55 Weight 83.9 kg
Sex Body mass index (BMI) 28.1 kg/m2
Marital status Temperature
Race/ethnicity Respiratory rate
Heart rate
Blood pressure
Chief Complaint
History of Present Illness (HPI)/Focused Orthopedic
Medications
Name Dose and Directions Indication
Allergies with Reactions
Past Medical History (PMH)
Surgeries & dates
Other (if applicable)
Vaccinations
Flu Date: Pneumovax Date: Tetanus Date:
, Family Hx (specify any disease and whether alive, or age at death)
Personal and Social Hx
Review of Systems (ROS)
List findings or check as negative. If you have a positive finding, then describe its seven
attributes in the HPI or PMH.
Body System Symptoms Findings
General Wgt. Δ, weakness, fatigue, fevers, pain
assessment
Skin Rash, lumps, sores, itching, dryness,
color change, Δ in hair/nails
Head Headache, head injury dizziness
Eyes Vision Δ, corrective lenses, last eye
exam date, pain, redness, excessive
tearing, double vision, blurred vision,
scotoma
Ears Hearing Δ, tinnitus, earaches,
Patient Demographics and Vital Signs
Patient initials Height 5'8"
Age 55 Weight 83.9 kg
Sex Body mass index (BMI) 28.1 kg/m2
Marital status Temperature
Race/ethnicity Respiratory rate
Heart rate
Blood pressure
Chief Complaint
History of Present Illness (HPI)/Focused Orthopedic
Medications
Name Dose and Directions Indication
Allergies with Reactions
Past Medical History (PMH)
Surgeries & dates
Other (if applicable)
Vaccinations
Flu Date: Pneumovax Date: Tetanus Date:
, Family Hx (specify any disease and whether alive, or age at death)
Personal and Social Hx
Review of Systems (ROS)
List findings or check as negative. If you have a positive finding, then describe its seven
attributes in the HPI or PMH.
Body System Symptoms Findings
General Wgt. Δ, weakness, fatigue, fevers, pain
assessment
Skin Rash, lumps, sores, itching, dryness,
color change, Δ in hair/nails
Head Headache, head injury dizziness
Eyes Vision Δ, corrective lenses, last eye
exam date, pain, redness, excessive
tearing, double vision, blurred vision,
scotoma
Ears Hearing Δ, tinnitus, earaches,
