comprehension patient history
Patient Name: ______________________________________________________________________ Age: ________ Sex: __________ Race: _________
Subjective Data Collection: Describe client chief complaint (C/C) in narrative format.
Past Medical History:
Allergies:
Medications:
Medical:
Surgical:
Health Maintenance: Last physical:
Immunizations and Date if known:
Recent travel or Military service:
Family Health History:
Psychiatric Health History:
Nutritional Health History:
Personal Habits: {Sleep patterns, health practices, Tobacco, Alcohol, Drugs, cultural/religious influences}
Review of systems:
Eyes:
Head, ears, nose, mouth, throat, neck:
Cardiovascular:
Respiratory:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Integumentary:
Neurological:
Endocrine:
Hematologic/Lymphatic:
Immunological:
Female/Male Reproductive Organs: {Breast, Scrotal, Rectal, Vaginal}
Physical Assessment: Objective Data collection
LOC: ______________________, Appearance: ________________________ Speech: _______________
Vital Signs: Blood Pressure: ___________, RR: _____________, HR: _____________,Temperature: _________, Height and Weight:___________________________
Clinical Findings: Describe patient assessment in narrative format.
Skin, Hair, Nails:
(Head, eyes, ears, nose, mouth, throat, neck, lymph) HEENT:
Respiratory system:
Cardiovascular system:
Gastrointestinal system:
Genitourinary:
Musculoskeletal system:
Neurological system (Document findings on CN I-VII):
Functional Assessment:
ASSESSMENT: (Top 5 assessment findings that have actual or potential risk factors).
- ___________________________________________________________________________________
2.___________________________________________________________________________________ 3.___________________________________________________________________________________ 4.___________________________________________________________________________________5.___________________________________________________________________________________
Completed by: ________________________________________________________________________
comprehension patient history
Patient Name: ______________________________________________________________________ Age: ________ Sex: __________ Race: _________
Subjective Data Collection: Describe client chief complaint (C/C) in narrative format.
Past Medical History:
Allergies:
Medications:
Medical:
Surgical:
Health Maintenance: Last physical:
Immunizations and Date if known:
Recent travel or Military service:
Family Health History:
Psychiatric Health History:
Nutritional Health History:
Personal Habits: {Sleep patterns, health practices, Tobacco, Alcohol, Drugs, cultural/religious influences}
Review of systems:
Eyes:
Head, ears, nose, mouth, throat, neck:
Cardiovascular:
Respiratory:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Integumentary:
Neurological:
Endocrine:
Hematologic/Lymphatic:
Immunological:
Female/Male Reproductive Organs: {Breast, Scrotal, Rectal, Vaginal}
Physical Assessment: Objective Data collection
LOC: ______________________, Appearance: ________________________ Speech: _______________
Vital Signs: Blood Pressure: ___________, RR: _____________, HR: _____________,Temperature: _________, Height and Weight:___________________________
Clinical Findings: Describe patient assessment in narrative format.
Skin, Hair, Nails:
(Head, eyes, ears, nose, mouth, throat, neck, lymph) HEENT:
Respiratory system:
Cardiovascular system:
Gastrointestinal system:
Genitourinary:
Musculoskeletal system:
Neurological system (Document findings on CN I-VII):
Functional Assessment:
ASSESSMENT: (Top 5 assessment findings that have actual or potential risk factors).
- ___________________________________________________________________________________
2.___________________________________________________________________________________ 3.___________________________________________________________________________________ 4.___________________________________________________________________________________5.___________________________________________________________________________________
Completed by: ________________________________________________________________________