Name: Social Hx:

Age/DOB: Born/Raised:
MRN:
HPI: Parents:

Siblings:

Education:

Employment:

Housing:

Relationship:

Kids:

Legal: Guns:

Religion: Military:
Substance Use: Rehab?
EtOH: (CAGE: Cut Down, Annoyed, Guilty, Eye Opener)

Cocaine:

Heroin:

Marijuana:

Other: Bath Salts, Herbals, Spice, K2, dust off

Tobacco: Pk yrs Caffeine:

Family Med Hx:
Pain: Provoked, Quality, Region/Radiation, Severity (1-10), Timing

Past Med Hx:

Dx:

ROS:
Hospitalizations:
GEN: wgt gain/loss, fatigue, fever, chills, weakness, sleep
HEENT: headache, pain, hearing, vision changes, dry mouth, throat
CV: chest pain, palp, tight
Outpt Physicians:
PULM: shortness of breath, wheezing, cough, sputum, pain
PCP:
GI: sore throat, heartburn, N/V, constipation, diarrhea
GU: urgency, frequency, incontinence
Allergies:
EXT/skin: bruises, swelling, edema, rashes, bruises
Physical Exam: Neuro: numbness, weakness, loss of vision, reflexes, tics/twitch
GEN: HEENT: Psych: Depression/anxiety, stress, dementia, trauma, self-harm,
SI/HI
CV: PULM: Current Meds: Drug/Dose/Route/Frequency/Indication/Last dose

ABD:

GU:

Ext/Skin:

Neuro: Vitals:
T:_____________ BP:________________ P:_____________
Wgt:___________ Resp:______________ O2:____________