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Patient LabelADULT INITIAL HISTORY AND PHYSICAL Today's Date: ___ / ___/ ___Age: ___Family Doctor: ___LEP: Interpreter ___Please complete the following information: What is the main reason for your
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How to fill out history and physical examination
How to fill out history and physical examination
01
Review the patient's medical records, including past medical history, medications, allergies, and any previous surgeries.
02
Introduce yourself to the patient and explain the purpose of the history and physical examination.
03
Begin by asking the patient about their chief complaint, medical history, family history, and social history.
04
Perform a thorough physical examination, including vital signs, general appearance, heart and lung auscultation, abdominal palpation, and neurological assessment.
05
Document all findings accurately in the patient's medical record for future reference.
Who needs history and physical examination?
01
Anyone seeking medical care or treatment requires a history and physical examination to assess their overall health status, identify any underlying medical conditions, and develop an appropriate treatment plan.
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What is history and physical examination?
History and physical examination is a comprehensive assessment of a patient's medical history and current physical condition.
Who is required to file history and physical examination?
Healthcare professionals such as doctors, nurses, and other medical practitioners 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 asking the patient questions about their medical history and performing a thorough physical assessment.
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, identify any potential health issues, and develop an appropriate treatment plan.
What information must be reported on history and physical examination?
History and physical examination reports typically include the patient's medical history, current symptoms, vital signs, physical findings, and any diagnostic test results.
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