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One Medical Center Drive, Lebanon, NH 03756 Preprocedure History & Physical Examination History & Physical completed by: ? DMC Staff Clinician Addressograph ? Non-Dutch Staff Clinician Chief Complaint/Diagnosis:

How to fill out history amp physical exam

How to fill out a history & physical exam:

1. Start by gathering the necessary information about the patient, such as their name, age, gender, and contact details.
2. Begin the history section by asking about the patient's chief complaints or reasons for seeking medical attention. Record their symptoms in detail, including the duration, intensity, and any associated factors.
3. Proceed to collect the patient's medical history, including past illnesses, surgeries, hospitalizations, and any chronic conditions they may have. Ask about their family history, as certain diseases can be hereditary.
4. Document the patient's current medications, including prescription drugs, over-the-counter medications, and any supplements they may be taking.
5. Inquire about the patient's allergies and note any adverse reactions they may have had in the past.
6. Ask about the patient's lifestyle habits, such as their diet, exercise routine, tobacco or alcohol use, and any recreational drug use. This information can provide insights into potential risk factors and overall health.
7. Perform a thorough physical examination, documenting the patient's vital signs (blood pressure, heart rate, respiratory rate, temperature, etc.), general appearance, and any abnormalities you may observe.
8. Systematically examine each body system, including cardiovascular, respiratory, neurological, musculoskeletal, and abdominal systems. Document any abnormalities, such as abnormal heart sounds or restricted range of motion.
9. If necessary, order and review relevant diagnostic tests, such as blood work, imaging studies, or electrocardiograms.
10. After completing the history and physical exam, summarize your findings, provide a differential diagnosis if possible, and develop a preliminary treatment plan or referral options.

Who needs a history & physical exam:

1. Individuals seeking medical care, whether for acute or chronic conditions, often require a history & physical exam.
2. It is crucial for patients who are new to a healthcare provider or institution, as it provides a comprehensive overview of their health status and aids in establishing a baseline.
3. People with existing medical conditions may need periodic history & physical exams to monitor their health, assess treatment effectiveness, or identify any potential complications.
4. Before certain procedures or surgeries, a history & physical exam is typically conducted to ensure the patient is in optimal health and minimize potential risks.
5. Employers may require history & physical exams for new employees, particularly for physically demanding or safety-sensitive roles.
6. Certain schools, colleges, or athletic programs may request history & physical exams as part of their enrollment requirements or participation in sports activities.
7. Insurance companies may request a history & physical exam for policy applicants as a part of the underwriting process, assessing potential risks and determining premium rates.
8. The elderly population or individuals with multiple comorbidities may benefit from regular history & physical exams to manage their complex medical conditions and prevent further complications.

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What is history amp physical exam?

History and physical exam is a comprehensive assessment of a patient's medical history, current health status, and physical examination findings.

Who is required to file history amp physical exam?

Healthcare professionals such as physicians, nurse practitioners, and physician assistants are required to file history and physical exams for their patients.

How to fill out history amp physical exam?

History and physical exams are typically filled out by documenting the patient's medical history, current symptoms, physical examination findings, and any additional relevant information.

What is the purpose of history amp physical exam?

The purpose of history and physical exam is to gather essential information about a patient's health to aid in diagnosis, treatment planning, and monitoring of their health status.

What information must be reported on history amp physical exam?

Information reported on history and physical exam includes patient demographics, past medical history, current medications, allergies, social history, family history, review of systems, and physical examination findings.