Encounter date: ________________________ SOAP Adult Patient Initials: __________ Gender: Male____ Female___ Transgender ____ Age: _____ Race: __________________ Chief Complaint: ________________________________________________________________ HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Allergies (Drug/Food/Environmental/Herbal):____________________________________________________________________________________________________________________________________________________________________________________________________________ Current perception of Health: Excellent Good Fair Poor PMH: ________________________________________________________________________ PSH: ________________________________________________________________________ Hospitalizations: ______________________________________________________________ Current Meds: ______________________________________________________________ Family History:_______________________________________________________________ Social history: __Married __Widowed __Single __ Divorced __Cohabitating Partner Lives: __Home __Alone __ Family __Caretaker __ACLF __ SNF ___Other: Smoke: ______________ETOH: ________________ Recreational Drug Use: _____________ Immunization HX: Please Document Date of Immunization or Date of Disease. Immunizations Pneumovac HPV HEP B MMR Varicella TD/Tdap FLU Other: DATE:_____ DATE:___ 1. 1. 1. 2. 2. 2. 3. Disease Review of Systems: General_______________________________________________________________________ HEENT_______________________________________________________________________ Neck________________________________________________________________________ Lungs ________________________________________________________________________ Cardiovascular ________________________________________________________________ Breast ________________________________________________________________________ GI ___________________________________________________________________________ Male/female genital _____________________________________________________________ GU __________________________________________________________________________ Neuro_________________________________________________________________________ Musculoskeletal________________________________________________________________ Activity & Exercise _____________________________________________________________ Psychosocial ___________________________________________________________________ Derm_________________________________________________________________________ Nutrition _______________________________________________ ...