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This document provides instructions for students and examining physicians regarding the completion of medical history and physical examination reports required for the Radiation Therapy Technology

How to fill out medical history and physical

How to fill out Medical History and Physical Examination Report Instruction Sheet

1. Begin by entering the patient's full name at the top of the sheet.
2. Fill in the date of birth and medical record number in the appropriate fields.
3. Complete the section on past medical history, noting any surgeries, chronic illnesses, or hospitalizations.
4. Fill out the family medical history, indicating any hereditary conditions.
5. Provide current medications and dosages, including over-the-counter drugs.
6. Answer questions related to allergies, specifying any known reactions.
7. Document the patient's lifestyle habits, including smoking, alcohol, and drug use.
8. Include information on immunizations and any relevant screenings.
9. Complete the physical examination section by noting vital signs and any observations.
10. Review the entire form for completion and accuracy before submission.

Who needs Medical History and Physical Examination Report Instruction Sheet?

1. The Medical History and Physical Examination Report Instruction Sheet is needed by healthcare providers, medical staff, and practitioners conducting patient assessments.
2. It is also necessary for patients being examined to provide comprehensive information about their health history.

People Also Ask about

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

Begin by entering your personal details in the designated fields at the top of the form. Next, provide information regarding any current medications and allergies. Finally, complete the evaluation of your health by filling out the sections regarding physical examination findings and other relevant medical history.

What does a history and physical H&P note include?

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.

How to write a patient report example?

Summary: The format of a patient case report encompasses the following five sections: an abstract, an introduction and objective that contain a literature review, a description of the case report, a discussion that includes a detailed explanation of the literature review, a summary of the case, and a conclusion.

How to write a case history of a patient?

Put details about the problem and related symptoms in a chronological order, as this will help with the clarity of your writing. Identify common psychiatric symptoms. Comment on the impact of the illness on the patient's life. Note details of previous treatment. Integrate current problem and psychiatric issues. Example 4:

What are examples of medical history?

Please list any past medical history below with date of onset or diagnosis. Examples include asthma, diabetes, depression, anxiety, drug or alcohol dependency, high blood pressure, thyroid disease, autoimmune disease, chronic pain, gynecologic disorder. Have you ever had surgery?

How do you write a patient history report?

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.

How do you document a patient's medical history?

Documentation of each patient encounter should include: Reason for encounter and relevant history. Appropriate history and physical exam in relationship to the patient's chief complaint. Review of lab, x-ray data and other ancillary services, where appropriate.

For pdfFiller’s FAQs

What is Medical History and Physical Examination Report Instruction Sheet?

The Medical History and Physical Examination Report Instruction Sheet is a document used to guide healthcare professionals in collecting and recording a patient's medical history and physical examination findings in a standardized manner.

Who is required to file Medical History and Physical Examination Report Instruction Sheet?

Healthcare providers such as physicians, nurse practitioners, and other licensed healthcare professionals who conduct medical examinations are required to file the Medical History and Physical Examination Report Instruction Sheet.

How to fill out Medical History and Physical Examination Report Instruction Sheet?

To fill out the Medical History and Physical Examination Report Instruction Sheet, providers should follow the outlined sections, gathering relevant patient information including personal details, medical history, medications, allergies, and results of the physical examination while ensuring accuracy and completeness.

What is the purpose of Medical History and Physical Examination Report Instruction Sheet?

The purpose of the Medical History and Physical Examination Report Instruction Sheet is to ensure that all relevant patient information is systematically collected for diagnosis, treatment planning, and continuity of care.

What information must be reported on Medical History and Physical Examination Report Instruction Sheet?

The information that must be reported includes patient identification details, comprehensive medical history, current medications, known allergies, pertinent family history, social history, and findings from the physical examination.