Interval health history and physical examination health history



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INTERVAL HEALTH HISTORY AND PHYSICAL EXAMINATION



HEALTH HISTORY:


Reason for today’s visit:

Current prescription or frequently used over the counter drugs

Allergies: Last Menstrual Period

Any changes in patient’s health since last visit? No  Yes 

Any surgery or hospitalization since last visit? No  Yes 

Any changes in your family medical or social history? No  Yes 




PHYSICAL EXAMINATION Normal Abn Comments


General Appearance

Nutritional Status

Skin

HEENT: Head: Fontanels, Scalp



Eyes: PERRL, Red Reflex

Ears: Canals, Drums

Nose & Sinuses

Mouth: Mucous Membrane

Gums, Teeth

Palate, Tongue

Throat: Tonsils

Neck: Thyroid

Lymph glands

Chest: Thorax



Lungs

Heart


Breast and axillae

Abdomen


Muscular Skeletal Back, Spine

Hip: Symmetry

Range of Motion

Posture


Extremities: Symmetry

Neurological: Gait

Balance


Reflexes

Female: External Genitalia

Male: Penis Female: Vagina

Testes Cervix

Scrotum Uterus


CHEST X-RAY RESULTS: Taken_________ Read_________ Compared with_________ ( ) Neg/Non-remarkable ( ) Improved ( ) Worsening ( ) No Change ( ) 0. No TB Exposure, Not Infected ( ) 1. TB Exposure, No Evidence of Infection ( ) 2. TB infection, Without Disease ( ) 3. TB Infection, With Disease ( ) 4. Inactive Disease ( ) 5. Suspect Site of Infection: Pulmonary ( ) Cavity ( ) Non Cavity Other _______________________________
Prostate Adnexa

Rectum Rectum

IMPRESSION/PLAN:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

S
CH-14 (Rev. 9/02)


IGNATURE:____________________________________________________________ DATE:_______________________________

INTERVAL HEALTH HISTORY AND PHYSICAL EXAMINATION



HEALTH HISTORY:


Reason for today’s visit:

Current prescription or frequently used over the counter drugs

Allergies: Last Menstrual Period

Any changes in patient’s health since last visit? No  Yes 

Any surgery or hospitalization since last visit? No  Yes 

Any changes in your family medical or social history? No  Yes 




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