Your Name, M.D

 

 

Patient First Name ________________ MI _____ Last Name: ____________________________

 

c Male c Female Age ___ __ Date of Birth _____________ Date of Exam _____________

 

Referred by ________________ Informant ____________________ Account # ________

c Initial Office Visit c Initial Office Consult c Multi-System c Single Organ

 

1. HISTORY OF PRESENT ILLNESS(S)

 

PROBLEM #1 (Chief Complaint):

 

Location:

 

Duration: Started ________________

 

Quality:

 

Severity: c Mild c Moderate c Severe c Varies

 

Timing: c Recurring ______________ per ____________ and each time lasting about _________

c Constantly present with/without changing severity

 

Context: c None c Occurred/occurring

 

Modifying factor: c None c Aggravated by c Relieved by

 

Associated signs & symptoms: c None c Associated with

 

 

 

PROBLEM #2

 

Location:

 

Duration: Started ________________

 

Quality:

 

Severity: c Mild c Moderate c Severe c Varies

 

Timing: c Recurring ______________ per ____________ and each time lasting about _________

c Constantly present with/without changing severity

 

Context: c None c Occurred/occurring

 

Modifying factor: c None c Aggravated by c Relieved by

 

Associated signs & symptoms: c None c Associated with

 

 

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