Med-Source

H&PE

Name: Sex: Age / DOB:

Date:

CC: Meds:

HPI:

Allergies:

Gen: fevers / chills /sweats / wt / fatigue

Skin: rashes / scaling / moles

Birth Hx:
Head: HA / faint / seizures / LOC / concussion

Eyes: blurry / double / pain / drainage / yellow / red

PMH:
Ears: hearing / ringing / discharge / dizzy

Nose: epistaxis / discharge / abnl odors / sinusitis

Throat: sore / hoarseness / cavities / ulcers

Breast: soreness / lumps / pain / discharge

Lungs: wheezing /cough / hemoptysis / clubbing

Immunizations?
♥: chest pain / pressure /palpitations / murmur /
PSH: orthopnea / edema

Heme: easy bruising / easy bleeding

GI: abd pain / N / V / D / C / hemat -emesis -chezia /

color / freq. / jaundice/ liver dz

GU: dysuria / hematuria / freq / urgency / incontinence /

discharge / testicular swelling, lumps, pain / impotence

menstrual: LMP _____ menarche______ regular?

Fam Hx: MI / HTN / ♥ / Ca / DM / osteo Musc: pain / swelling / stiffness / ROM limitation / fx

Neuro: weakness / spasticity / tremor / involuntary

Psych: mood / anxiety /memory / sleep

Social Hx:

Tobacco______________ EtOH_________________ IVDU/other__________________

 Med-Source
VS T: HR: BP: RR: Pox
H&PE
GEN:

HEENT::

RESP:

CV:

ABD:

GU:

MUSC: reflexes / sensory

SKIN:

CBC:

CK: CK-MB: RI: Troponin:

BC:

CXR:

ECG:

UA / UC: