Patient Initials: Pt. Encounter Number: Date: Age: Sex: Allergies: Advanced Directives: SUBJECTIVE CC: HPI: Describe the course of the patient’s illness: Onset: Location: Duration: Characteristics: Aggravating Factors: Relieving Factors: Treatment: Current Medications: PMH Medication Intolerances: Chronic Illnesses/Major traumas: Screening Hx/Immunizations Hx: Hospitalizations/Surgeries: Family History: Social History: ROS General Cardiovascular Skin Respiratory Eyes Gastrointestinal Ears Genitourinary/Gynecological Nose/Mouth/Throat Musculoskeletal Breast Neurological Heme/Lymph/Endo Psychiatric OBJECTIVE Weight BMI Temp BP Height Pulse Resp PHYSICAL EXAMINATION General Appearance Skin HEENT Cardiovascular Respiratory Gastrointestinal Breast Genitourinary Musculoskeletal Neurological Psychiatric Lab Tests Special Tests Diagnosis · Primary Diagnosis-  Evidence for primary diagnosis should be documented in your Subjective and Objective exams. o Differential Diagnoses- Include three diagnoses PLAN including education o Plan:  Further testing  Medication  Education  Non-medication treatments · Referrals  Follow-up visits References .

1. Patient Initials:
Pt. Encounter Number:
Date:
Age:
Sex:
Allergies:
Advanced Directives:
SUBJECTIVE
CC:
HPI: Describe the course of the patient’s illness:
Onset:
Location:
Duration:
Characteristics:
Aggravating Factors:
Relieving Factors:
Treatment:
Current Medications:
PMH
Medication Intolerances:
Chronic Illnesses/Major traumas:
Screening Hx/Immunizations Hx:
Hospitalizations/Surgeries:

2. Family History:
Social History:
ROS
General
Cardiovascular
Skin
Respiratory
Eyes
Gastrointestinal
Ears
Genitourinary/Gynecological
Nose/Mouth/Throat
Musculoskeletal
Breast
Neurological
Heme/Lymph/Endo

3. Psychiatric
OBJECTIVE
Weight BMI
Temp
BP
Height
Pulse
Resp
PHYSICAL EXAMINATION
General Appearance
Skin
HEENT
Cardiovascular
Respiratory
Gastrointestinal
Breast
Genitourinary
Musculoskeletal
Neurological
Psychiatric
Lab Tests

4. Special Tests
Diagnosis
· Primary Diagnosis-
Evidence for primary diagnosis should be documented in
your Subjective and
Objective exams.
o Differential Diagnoses- Include three diagnoses
PLAN including education
o Plan:
Further testing
Medication
Education
Non-medication treatments
· Referrals
Follow-up visits
References