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COMMUNITY CARE FOSTER FAMILY HOME ANNUAL HISTORY AND PHYSICAL EXAM FORM (PLEASE REVIEW ITEMS LISTED, UPDATE ANY INACCURACIES, AND COMPLETE BLANK SECTIONS.)CLIENT INFORMATION: NAME: PHONE:ADDRESS: BIRTHDATE:PHYSICIAN:PHONE:SEX:AGE:FAX:II.

How to fill out history and physical exam

How to fill out history and physical exam:

1. Collect patient's demographic information, including name, age, gender, and contact details.
2. Obtain a thorough medical history, including past illnesses, surgeries, medications, allergies, and family medical history.
3. Document the patient's chief complaint or reason for the visit, along with the onset, duration, and any associated symptoms.
4. Perform a comprehensive physical examination, including vital signs (temperature, blood pressure, heart rate, and respiratory rate), general appearance, head-to-toe assessment, and specialized examinations based on patient complaints or medical history.
5. Record findings accurately and objectively, including pertinent positive and negative findings.
6. Include relevant laboratory and diagnostic test results, such as blood tests, imaging studies, or electrocardiograms.
7. Summarize the assessment and develop a differential diagnosis based on the collected information.
8. Formulate a treatment plan, including therapeutic interventions, referrals, or further diagnostic tests if needed.
9. Provide appropriate patient education regarding the findings, treatment options, and preventive measures.

Who needs history and physical exam?

1. Patients visiting healthcare professionals for routine check-ups or preventive screenings.
2. Individuals with specific medical concerns, symptoms, or illnesses.
3. Patients preparing for surgery or undergoing medical procedures.
4. Athletes undergoing sports physicals or pre-participation evaluations.
5. Individuals applying for certain jobs or academic programs that require a medical evaluation.
6. Patients involved in legal proceedings or insurance claims requiring an objective medical assessment.

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What is history and physical exam?

A history and physical exam (H&P) is a comprehensive medical assessment that includes a patient's medical history, presenting symptoms, and a physical examination conducted by a healthcare provider to evaluate the patient's health condition.

Who is required to file history and physical exam?

Typically, healthcare providers, such as physicians and advanced practice nurses, are required to file a history and physical exam for patients before any surgical or diagnostic procedures, as well as for new patients during initial visits.

How to fill out history and physical exam?

To fill out a history and physical exam, the healthcare provider should gather information on the patient's medical history, family history, social history, review of systems, and perform a physical examination, documenting findings clearly and concisely in the designated forms.

What is the purpose of history and physical exam?

The purpose of a history and physical exam is to establish a baseline of the patient's health, identify any existing health issues, guide diagnosis and treatment, and ensure that any planned procedures are safe and appropriate.

What information must be reported on history and physical exam?

The information that must be reported includes the patient's personal details, chief complaint, history of present illness, past medical history, medication history, allergies, family history, social history, review of systems, and findings from the physical examination.