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HISTORY AND PHYSICAL This document consists of a two paged History and Physical. It is to be completed by a Physician, Nurse Practitioner or Physicians Assistant, signed and dated on page 2. STUDENTS

How to fill out history and physical

How to fill out history and physical:

1. Start by gathering relevant information from the patient. This includes personal details such as name, age, and contact information. Additionally, ask about their medical history, including any past illnesses or surgeries, current medications, and any known allergies.
2. Next, conduct a thorough review of systems. This involves asking specific questions about each organ system to identify any current or potential health issues. Document any symptoms experienced by the patient, such as pain, dizziness, or fatigue.
3. Perform a detailed physical examination of the patient. This includes assessing vital signs, such as blood pressure, heart rate, and respiratory rate. Examine each body system, such as the cardiovascular, respiratory, and musculoskeletal systems, documenting any abnormal findings.
4. Obtain a complete medical and family history. Ask the patient about any past or present medical conditions they have or have had, as well as any significant medical conditions that run in their family. This information helps in identifying potential genetic or hereditary conditions.
5. Document any diagnostic tests or imaging studies that have been performed on the patient. This includes laboratory results, X-rays, CT scans, or any other tests that can provide additional information about the patient's health status.
6. Finally, compile all the gathered information into a comprehensive history and physical report. Ensure that the report is organized and easy to read, including sections for the patient's personal information, medical history, review of systems, physical examination findings, any diagnostic test results, and an assessment and plan for further treatment or investigations.

Who needs history and physical:

1. Patients undergoing surgery: History and physical examinations are essential before any surgical procedure to evaluate the patient's overall health, identify potential risks or complications, and determine the suitability for surgery.
2. Individuals seeking new healthcare providers: When visiting a new doctor or healthcare facility, providing a detailed history and physical helps the provider understand the patient's medical background and establish a baseline for their ongoing care.
3. Pre-employment or insurance requirements: Certain job positions or insurance policies may require a history and physical examination to ensure the individual is fit for the specific job or to assess any pre-existing conditions that may impact coverage or premiums.
4. Regular check-ups and preventative care: History and physical examinations are fundamental components of routine healthcare visits to monitor the patient's overall health, identify any emerging issues, and provide appropriate preventive measures.

In summary, filling out a history and physical requires gathering patient information, conducting a comprehensive review of systems and physical examination, documenting medical and family history, including diagnostic tests, and compiling all the information into a detailed report. History and physicals are necessary for patients before surgery, individuals seeking new healthcare providers, those undergoing pre-employment or insurance evaluations, and for regular check-ups and preventive care.

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What is history and physical?

History and physical is a medical report that details a patient's medical history and current physical condition.

Who is required to file history and physical?

Healthcare providers such as doctors, nurses, and physician assistants are required to file history and physical for patients.

How to fill out history and physical?

History and physical is filled out by conducting a thorough interview with the patient to gather information about their medical history and performing a physical examination.

What is the purpose of history and physical?

The purpose of history and physical is to provide healthcare providers with important information about a patient's health status to aid in diagnosis and treatment.

What information must be reported on history and physical?

Information such as past medical history, current medications, allergies, family history, and physical examination findings must be reported on history and physical.