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This document collects health history and physical examination details from students applying to Grand Canyon University's Athletic Training Education Program, ensuring they meet the physical and

How to fill out health history and physical

How to fill out Health History and Physical Examination Report

1. Begin with personal information: Fill in the patient's full name, date of birth, address, and contact details.
2. Record medical history: Include previous illnesses, surgeries, and any chronic conditions.
3. Note family history: Document any significant health issues in immediate family, such as heart disease, diabetes, or cancer.
4. List medications: Include current prescriptions, over-the-counter drugs, and supplements being taken by the patient.
5. Document allergies: Specify any known allergies to medications, foods, or environmental factors.
6. Assess lifestyle factors: Record details about the patient's diet, exercise habits, alcohol consumption, and tobacco use.
7. Conduct a physical examination: Collect vital signs (blood pressure, heart rate, temperature), and perform a systematic examination of body systems.
8. Summarize findings: Provide a brief overview of the overall health status based on the history and examination.
9. Sign and date the report: Ensure the report is signed by the healthcare provider and dated.

Who needs Health History and Physical Examination Report?

1. Individuals undergoing a routine checkup or annual physical examination.
2. Patients seeking assessment before a medical procedure or surgery.
3. People applying for jobs that require a health screening.
4. Athletes needing a physical examination for participation in sports.
5. Individuals seeking insurance coverage that requires health assessment.

People Also Ask about

What are some normal physical examination findings?

Normal findings include: Eyes: Pupils are equal and reactive to light. Ears: No signs of infection or wax buildup. Nose: Clear nasal passages without congestion. Throat: Pink and moist mucous membranes. Lymph Nodes: Not swollen or tender to touch.

What information must be included in the history and physical examination?

Patient age. diagnoses, the type and number of surgeries and procedures scheduled to be performed, comorbidities, and the level of anesthesia required for the surgery or procedure.

What does a history and physical consist of?

The H&P: History and Physical is the most formal and complete assessment of the patient and the problem. H&P is shorthand for the formal document that physicians produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending.

How to write history and physical examination?

The HPI should be written in prose with full sentences and be a narrative that builds an argument for the reason the patient was admitted. ​ Has a starting point (i.e. “the patient was in her usual state of health until 5 days prior to admission.). ​ Has appropriate flow, continuity, sequence, and chronologic order.

What should be included in an H&P?

It includes the patient's age, gender, most pertinent past medical history and major symptoms(s) and duration. Whenever possible, this statement should identify the significant issue from the patient's perspective, and include the patient's words if the patient accurately represents the reason for the presentation.

What is included in a history and physical exam?

Although it is called "History and Physical," it includes an assessment and plan. The assessment may be a differential diagnosis, a list of symptoms, or a problem list. In annual preventative health assessments, we will have goals to accomplish: i.e., weight loss, BP < 130/80, etc.

For pdfFiller’s FAQs

What is Health History and Physical Examination Report?

A Health History and Physical Examination Report is a comprehensive document that summarizes a patient's medical history, including past illnesses, surgeries, family health issues, and a physical examination performed by a healthcare provider.

Who is required to file Health History and Physical Examination Report?

Typically, healthcare providers such as doctors, nurse practitioners, and physician assistants are required to file a Health History and Physical Examination Report for patients prior to medical treatments, admissions to healthcare facilities, or specific evaluations.

How to fill out Health History and Physical Examination Report?

To fill out a Health History and Physical Examination Report, a healthcare provider should gather the patient's medical history, perform a physical examination, record findings systematically, and ensure all areas are covered including personal history, family history, and present health status.

What is the purpose of Health History and Physical Examination Report?

The purpose of a Health History and Physical Examination Report is to provide a comprehensive overview of a patient's health status to inform treatment decisions, establish a baseline for future healthcare needs, and facilitate communication between healthcare providers.

What information must be reported on Health History and Physical Examination Report?

Essential information that must be reported includes personal identification details, a detailed health history (including medical, surgical, and family history), findings from the physical examination, any current medications, allergies, and relevant lifestyle information.