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This document provides instructions for students and examining physicians on how to complete the medical history and physical examination report required for the Radiation Therapy Technology Program

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 personal information such as name, date of birth, and contact details.
2. Provide the patient's medical history including any past illnesses, surgeries, and chronic conditions.
3. Include a list of current medications, dosages, and any allergies.
4. Document the family medical history, noting any hereditary conditions.
5. Fill out the physical examination section, detailing findings from the head-to-toe assessment.
6. Complete any additional sections as required, such as social history or review of systems.
7. Review the completed form for accuracy and ensure all sections are filled out appropriately.
8. Sign and date the report before submission.

Who needs Medical History and Physical Examination Report Instruction Sheet?

1. Healthcare providers requiring detailed patient information for diagnosis and treatment.
2. Insurance companies for claims processing.
3. Research facilities for clinical studies or health assessments.
4. Legal entities requiring documentation in cases of medical disputes.

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 gather and summarize an individual's medical history and the findings from a physical examination.

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

Typically, healthcare providers, such as doctors and medical professionals, are required to fill out and file the Medical History and Physical Examination Report Instruction Sheet for their patients.

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

To fill out the Medical History and Physical Examination Report Instruction Sheet, one should carefully follow the provided guidelines, ensuring to input accurate and complete information regarding the patient's medical history, physical examination results, and relevant notes.

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 healthcare providers have a comprehensive understanding of a patient's medical background and current health status, facilitating proper diagnosis and treatment.

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

The information that must be reported includes the patient's demographics, past medical history, current medications, allergies, family history of diseases, vaccination history, and findings from the physical examination including vitals and any abnormalities.