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History and Physical Examination Form CHIEF COMPLAINT/MEDICAL PROBLEM: PAST MEDICAL HISTORY: CURRENT MEDICAL HISTORY: NOCTURNAL REFLUX: Y or N APOPLEXY: Y or N NOCTURIA: Y or N SLEEP PARALYSIS: Y

How to fill out history and physical examination

How to fill out history and physical examination:

1. Begin by gathering necessary information about the patient, including their personal details, medical history, and reason for the examination.
2. Document the patient's chief complaint or presenting problem in detail, including any relevant symptoms or concerns they may have.
3. Take a thorough medical history, including information about past illnesses, surgeries, medication use, allergies, and family medical history.
4. Conduct a physical examination, systematically assessing each major body system. This may include checking vital signs, examining the head and neck, listening to the heart and lungs, and examining the abdomen, among other things.
5. During the physical examination, make note of any abnormal findings, such as abnormal heart sounds, enlarged lymph nodes, or abnormal skin lesions.
6. After completing the examination, summarize your findings and provide a clear, concise assessment of the patient's overall health status.
7. If necessary, order additional diagnostic tests or consultations with specialists to further evaluate any abnormal findings or concerns.
8. Finally, create a comprehensive plan for the patient's ongoing care, including any necessary follow-up appointments, referrals, or treatments.

Who needs history and physical examination:

1. Individuals seeking routine healthcare or preventive screenings may need a history and physical examination. This is commonly done during annual check-ups or pre-employment screenings.
2. Patients with specific symptoms or medical concerns may require a history and physical examination to help determine the underlying cause of their condition.
3. Individuals preparing for surgeries or other invasive procedures often undergo a history and physical examination to assess their overall health and identify any potential risks or complications.

Note: It is important to consult with a healthcare professional for specific guidance and instructions on how to fill out a history and physical examination form, as practices and requirements may vary.

For pdfFiller’s FAQs

What is history and physical examination?

History and physical examination is a medical assessment conducted by healthcare professionals to gather information about a patient's medical history, current health status, and to perform a physical examination of their body.

Who is required to file history and physical examination?

History and physical examination reports are typically filed by healthcare providers, such as doctors or nurses, who have conducted the examination and have access to the patient's medical records.

How to fill out history and physical examination?

Filling out a history and physical examination form typically involves documenting the patient's personal details, medical history, current symptoms, conducting a physical examination, and recording the findings accurately. It is usually done in a structured format provided by the healthcare facility.

What is the purpose of history and physical examination?

The purpose of history and physical examination is to assess a patient's overall health, identify any existing medical conditions, determine the best course of treatment, monitor progress, and establish a baseline for future medical evaluations.

What information must be reported on history and physical examination?

A history and physical examination report may include details such as the patient's demographics, medical history, current medications, allergies, vital signs, general appearance, systemic examination findings, and any abnormal findings or significant observations made during the examination.

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