Get the free INITIAL HISTORY AND PHYSICAL - Stop TB Partnership - stoptb

INITIAL HISTORY AND PHYSICAL Patient ID Date District / Facility / Day Month Year Serial no. Facility ID (if different) Patient Last Name BACKGROUND Sex: Female Male / Date of birth: / / / Month Year

How to fill out initial history and physical

How to fill out initial history and physical:

1. Begin by gathering the patient's personal information, including their full name, date of birth, contact information, and any applicable identification numbers.
2. Record the reason for the visit or the chief complaint, which is the main issue the patient is experiencing or the purpose of their appointment.
3. Document the patient's medical history, including any past and current illnesses, surgeries, allergies, medications, and family history of diseases.
4. Ask the patient about their social history, including their occupation, lifestyle habits such as smoking or alcohol consumption, and any significant life events that may impact their health.
5. Conduct a review of systems, where you systematically ask the patient about any symptoms or problems related to each major body system, such as cardiovascular, respiratory, gastrointestinal, and musculoskeletal.
6. Perform a thorough physical examination, including vital signs (such as blood pressure, heart rate, and temperature) and a detailed assessment of each body system.
7. After completing the history and physical examination, generate a list of potential diagnoses or differential diagnoses based on the information obtained.
8. Discuss and review the findings with the patient, explaining any necessary tests or further evaluations that may be needed.
9. Create a treatment plan that includes recommendations for further investigations, medications, referrals, or lifestyle modifications.

Who needs initial history and physical?

1. Patients who are new to a healthcare provider or facility typically need an initial history and physical examination. This helps establish a baseline of their health status and provides crucial information for future healthcare interactions.
2. Individuals who are undergoing a pre-employment medical examination may require an initial history and physical. Employers often require this to ensure that prospective employees are fit for the job and do not have any conditions that may pose a risk in the workplace.
3. Patients who are scheduled for certain medical procedures or surgeries may need an initial history and physical. This helps determine their overall health status and identify any factors that may affect the safety and success of the procedure.
4. Individuals participating in sports or physical activities that require a thorough evaluation of their health and physical abilities may need an initial history and physical examination. This helps ensure that they are medically cleared to engage in these activities without compromising their well-being.
5. In some cases, individuals seeking life or health insurance coverage may be required to undergo an initial history and physical examination. Insurance companies use this information to assess the individual's risk profile and determine the appropriate coverage and premium rates.

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