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I'm History and Physical Examination Form (Page 1 of 3). GHA FORM # 0286 STOCK # 990286. FORM REVISED: 03/2011. APPROVED DATE: Medicine ...

How to fill out im history and physical

To fill out an IM (Internal Medicine) history and physical, follow these steps:

1. Begin by collecting the patient's demographic information, including their name, date of birth, contact information, and insurance details.
2. Proceed to document the patient's chief complaint or reason for the visit. This can be a specific symptom, ongoing medical condition, or a general check-up.
3. Take a thorough medical history, including information about past medical conditions, surgeries, allergies, medications, and any family history of diseases.
4. Perform a review of systems, which involves systematically asking the patient about any symptoms they may be experiencing in various bodily systems, such as respiratory, cardiovascular, gastrointestinal, etc.
5. Conduct a comprehensive physical examination, evaluating the patient's general appearance, vital signs (such as blood pressure, heart rate, and temperature), auscultating the heart and lungs, palpating various body parts, and assessing neurological function.
6. Include necessary laboratory and diagnostic test results, such as blood work, imaging studies, EKGs, or any other tests relevant to the patient's condition.
7. Record a detailed assessment of the patient's current condition, based on the medical history, physical examination findings, and test results.
8. Develop an appropriate plan of care, which may include further diagnostic investigations, medication prescriptions, referrals to specialists, lifestyle modifications, or follow-up appointments.

IM histories and physicals are typically needed by patients who require comprehensive medical assessments or those seeking primary care. It is a crucial component for establishing a baseline of health, managing chronic conditions, monitoring progress, or preparing for specialized treatments.

For pdfFiller’s FAQs

What is im history and physical?

IM history and physical is a medical report detailing a patient's medical history and current physical condition.

Who is required to file im history and physical?

Healthcare providers such as doctors, nurses, and physicians assistants are required to file an IM history and physical for their patients.

How to fill out im history and physical?

IM history and physical forms can be filled out by documenting the patient's medical history, current medications, allergies, and performing a physical examination.

What is the purpose of im history and physical?

The purpose of IM history and physical is to provide healthcare providers with important information about a patient's health status in order to make informed decisions about their care.

What information must be reported on im history and physical?

Information such as medical history, current medications, allergies, physical examination findings, and any relevant test results must be reported on an IM history and physical.

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