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This document serves as a comprehensive form to collect patient history and perform a physical examination, including various assessments and findings related to the patient's health.

How to fill out history and physical exam

How to fill out History and Physical Exam Form

1. Begin with personal information: Fill in the patient's name, date of birth, and contact details.
2. Provide the patient's medical history: Include past illnesses, surgeries, and current medications.
3. Document family medical history: Note any hereditary conditions or significant health issues in the family.
4. Review the patient's social history: Record information about lifestyle, occupation, and habits such as smoking or alcohol use.
5. Conduct a systems review: Check for symptoms in various body systems (e.g., cardiovascular, respiratory).
6. Complete the physical examination section: Document findings from the physical exam, including vital signs and any notable observations.
7. Sign and date the form: Ensure that the form is dated and signed by the healthcare provider.

Who needs History and Physical Exam Form?

1. Patients undergoing a routine check-up or a new medical evaluation.
2. Individuals being admitted to a hospital or healthcare facility.
3. Patients requiring pre-operative assessments before surgery.
4. Insurance companies needing documentation for coverage.
5. Healthcare providers needing comprehensive patient information for diagnosis and treatment planning.

People Also Ask about

What is the full history and physical exam?

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 present examination findings?

If incorporating examination findings into a presentation, positive and relevant negative findings should be provided rather than recounting the whole examination. Providing the NEWS score and stating which observations are abnormal is good practice. This is especially important for sick patients.

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 is the history and physical exam?

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.

Why is physical examination and history taking important?

Test results plus findings from the history and physical examination may confirm or refute the main and differential diagnoses, setting up either a management plan or the need for an alternative hypothesis.

How do you document a patient's history?

The history should be described in chronological order. Past Medical History (PMH): Whereas the HPI is recorded in paragraph form, it is important to keep the PMH in list form, and brief. Within each category, information should be in chronological order.

What is the main purpose of the physical examination?

During a physical examination, a health care provider checks your body to determine if you do or do not have a physical problem. A physical examination usually includes: Inspection (looking at the body) Palpation (feeling the body with fingers or hands)

For pdfFiller’s FAQs

What is History and Physical Exam Form?

The History and Physical Exam Form is a medical document that compiles a patient's medical history and results from a physical examination, used to assess the patient's health status and inform treatment decisions.

Who is required to file History and Physical Exam Form?

Healthcare providers, such as doctors and nurses, are required to file a History and Physical Exam Form for all new patients and under certain circumstances for existing patients, particularly before surgeries or significant medical procedures.

How to fill out History and Physical Exam Form?

To fill out the History and Physical Exam Form, a healthcare professional should accurately document the patient's medical history, including previous illnesses, surgeries, family history, medications, allergies, and findings from the physical examination.

What is the purpose of History and Physical Exam Form?

The purpose of the History and Physical Exam Form is to provide a comprehensive overview of a patient's health status, facilitating diagnosis, treatment planning, and continuity of care.

What information must be reported on History and Physical Exam Form?

The History and Physical Exam Form must report information such as the patient's demographic data, chief complaint, medical history, family history, social history, review of systems, and the results of the physical examination.