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History and Physical Examination 300 Bernie Avenue, Suite 201 Springfield, MA 011071107 ×413× 7854666 www.neortho.com Date Patients Name Primary Care Doctor Reason for Visit (Chief Complaint) Date

How to fill out history and physical examination

How to fill out history and physical examination:

1. Gather all necessary forms and documents related to the patient's medical history. These may include previous medical records, laboratory results, and diagnostic reports.
2. Begin by documenting the patient's demographics, such as their name, age, gender, and contact information.
3. Obtain a thorough medical history by asking the patient about any pre-existing medical conditions, previous surgeries or hospitalizations, allergies, and current medications. Document this information accurately and completely.
4. Conduct a detailed review of systems by asking the patient about their symptoms or issues related to each major organ system, such as cardiovascular, respiratory, gastrointestinal, and musculoskeletal systems.
5. Perform a comprehensive physical examination, starting from head to toe. Document findings related to vital signs, general appearance, mental status, skin condition, and any abnormalities in each body system examined.
6. Incorporate specific assessments based on the patient's complaints or concerns. For example, if the patient complains of chest pain, perform a focused examination of the cardiovascular system.
7. Record any diagnostic tests or imaging studies ordered during the examination, along with the results and interpretation.
8. Summarize the findings and impressions based on the history and physical examination. Ensure that the summary is clear and concise, conveying the essential information.
9. Provide a comprehensive assessment and plan, which may include further investigations, referrals, or treatments based on the current findings.
10. Always document accurately, legibly, and in a timely manner, adhering to the standard guidelines and requirements of your healthcare facility.

Who needs history and physical examination?

1. Patients visiting a healthcare provider for the first time typically require a comprehensive history and physical examination. This allows the healthcare provider to establish a baseline understanding of the patient's health.
2. Patients requiring medical clearance for certain activities or procedures, such as surgeries, employment, or participation in sports, may need a history and physical examination to ensure they are fit for the specific activity.
3. Individuals with chronic medical conditions may undergo regular history and physical examinations to monitor their disease progression, assess the effectiveness of treatments, and identify any new or worsening symptoms.
4. Patients experiencing new or concerning symptoms may undergo a history and physical examination to determine the underlying cause and guide further diagnostic and treatment decisions.
5. In some cases, history and physical examinations are performed as part of routine check-ups or preventive care visits to identify potential health issues before they progress.

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What is history and physical examination?

History and physical examination is a medical evaluation process where a healthcare provider gathers information about a patient's medical history, symptoms, and performs a physical examination to assess their overall health.

Who is required to file history and physical examination?

Healthcare providers such as doctors, nurse practitioners, and physician assistants are required to file history and physical examinations for their patients.

How to fill out history and physical examination?

History and physical examinations are typically filled out by conducting interviews with the patient to gather their medical history, performing a physical examination, and documenting the findings in a medical report.

What is the purpose of history and physical examination?

The purpose of history and physical examination is to gather information about a patient's health status, diagnose medical conditions, and create a treatment plan.

What information must be reported on history and physical examination?

Information reported on history and physical examination includes patient's medical history, current symptoms, vital signs, physical examination findings, and any diagnostic test results.