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History and Physical (please print) Patient Name: Height: Weight: List Present Medication/Supplements and dosages: Any Medication Allergies: Yes or No Explain: Latex Allergy: Yes or No Have you been

How to fill out history and physical please

How to fill out history and physical:

1. Begin by gathering the patient's personal information, such as their name, age, and contact details.
2. Then, document the reason for the patient's visit, including their chief complaint or primary symptom.
3. Take a detailed medical history by asking about any past illnesses, surgeries, or chronic conditions the patient may have had.
4. Ask about the patient's family medical history, including any hereditary diseases or conditions that may be relevant.
5. Inquire about the patient's current medications, including any prescription drugs, over-the-counter medications, or supplements they may be taking.
6. Document any known allergies or adverse reactions the patient may have to medications or substances.
7. Conduct a thorough review of systems by asking about the patient's symptoms in each body system, such as respiratory, cardiovascular, gastrointestinal, etc.
8. Perform a physical examination, including vital signs, general appearance, palpation, auscultation, and any other relevant assessments.
9. Record the findings from the physical examination accurately and objectively, avoiding any personal biases or assumptions.
10. Finally, summarize the patient's medical history, physical examination findings, and provide a provisional diagnosis or differential diagnosis.

Who needs history and physical:

1. Patients scheduled for surgery: Prior to any surgical procedure, a history and physical examination are typically required to assess the patient's overall health and identify any potential risks or complications.
2. New patients: Physicians often require a comprehensive history and physical for new patients to establish a baseline and gather important information about their medical background.
3. Insurance companies: A history and physical may be necessary for insurance purposes, especially when applying for life insurance or disability benefits.
4. Employers: Some employers may require a history and physical examination as part of their pre-employment screening process to ensure the individual is physically fit for the job.
5. Sports organizations: Athletes, especially those participating in contact or high-risk sports, may be required to undergo a history and physical to ensure they are in good health and able to engage in physical activities safely.

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What is history and physical please?

History and physical refers to the documentation of a patient's medical history and current physical status.

Who is required to file history and physical please?

Healthcare providers such as doctors, nurses, and other medical professionals are required to file history and physical documents.

How to fill out history and physical please?

History and physical forms are typically filled out by the healthcare provider during a patient's initial visit or admission.

What is the purpose of history and physical please?

The purpose of history and physical documentation is to provide a comprehensive overview of the patient's health status to aid in diagnosis and treatment planning.

What information must be reported on history and physical please?

Information such as medical history, current medications, allergies, vital signs, and physical examination findings must be reported on history and physical documents.