Initial Intake
Age: years old
Gender:
HISTORY:
Presents for a first visit
Past medical history:
Medications:
Allergies: ,
Family history: ,
Social history:
Smoking: , pack-years
Alcohol: , drinks per
Recreational drugs: ,
Diet: , , , ,
Physical activity:
Occupation:
Living with:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Eyes: conjunctiva/sclera , lids/lashes , cornea , , extraocular movements , OD 20/, OS 20/
Ears: tympanic membranes , auditory canal on , hearing
Nose: , discharge ,
Throat: , , ,
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Breasts: , ,
Abdomen: , , ,
Anorectal: DRE , prostate , , , anus
Pelvic: external genitalia , vagina , cervix , uterus , adnexa ,
Genital: penis , testes and epididymis ,
Skin: on
Extremities: , , cap refill sec, pulses , ,
Musculoskeletal: joints ,
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , speech , mood , thought , , judgment
PLAN:
Investigations:
- Blood work: , , , , , , , , ,
- Urinalysis
- ECG
- Chest X-ray
- Mammogram
- Pap smear
- Bone density scan
- Colonoscopy
- Vision screening
- Hearing screening
Treatments:
- Lifestyle counseling: , , ,
- Immunizations: , , , ,
-
-
Further care:
- Referral to dietitian
- Follow-up in
- Return if new symptoms develop
HISTORY: EXAM: PLAN: