Download this pdf and you'll never miss an H&P element again. By using this H&P tool to record your patient's chief complaint and history (HPI, ROS, and PFSH), medications and allergies, and your physical exam, assessment and treatment plan, you will get the reimbursement you deserve for every visit.

1. History & Physical template June 2016 by K. Sherman Pg. 1 of 4
Patient Name: ____________________________
Date of Service: ___________________________
History & Physical
HISTORY OF PRESENT ILLNESS
PAST HISTORY
MEDICAL/SURGICAL:
□ Pregnant □ Tested
DRUG ALLERGIES
□ None
LIST:
FAMILY:
SOCIAL:
□ Tobacco Use: _________________ If yes, smoking cessation counseling provided □ Yes □ No Duration ___________
□ Alcohol Use: ____________________ □ Recreational Drugs: ____________________
REVIEW OF SYSTEMS: WNL Abnormal/ Comment
Constitutional
Eyes
ENMT
Neck
CV
Resp
GI
GU
Heme/Lymph
Musculoskeletal
Skin/Breasts
Neuro
Psych
Allergy/Immuno
CHIEF COMPLAINT: DATE OF ACCIDENT:
PROPOSED OPERATION/PROCEDURE: REFERRED BY:

2. History & Physical template June 2016 by K. Sherman Pg. 2 of 4
Patient Name: ____________________________
Date of Service: ___________________________
MEDICATIONS
Medication Name DOSE ROUTE FREQUENCY
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

3. History & Physical template June 2016 by K. Sherman Pg. 3 of 4
Patient Name: ____________________________
Date of Service: ___________________________
PHYSICAL EXAMINATION Vital Signs
Ht: Wt: BMI: B/P: Temp:
EXAM: WNL NOTE ABNORMAL FINDINGS
Pertinent Data
Reviewed:
Constitutional General appearance Radiology:
□ Reviewed □ Interpreted
Eyes
□ Pupils/Sclera
ENMT
Neck
Appearance □ Veins □ Trachea midline □ Thyroid □ Bruits
Resp
□ Respiratory effort □ Auscultation □ Percussion □ Palpation
CV □ Rhythm □ Murmur □ Gallup □ Rub
Chest/Breasts
GI □ Tenderness □ Masses □ Organomegaly □ Pulsation
EKG/ECHO/OTHER:
□ Reviewed □ Interpreted
GU □ Genitalia □ Rectal/pelvic
Lymph □ Adenopathy
MS/Extremities
□ Gait and station □ Digits and nails □ Joints, bones, and muscles
Areas examined: □ head and neck □ spine, ribs and pelvis, □ rt upper extremity
□ lt upper extremity □ rt lower extremity □ lt lower extremity
Skin □ Inspection □ Palpation □ Rash □ Wound □ Scars
Neuro LABS:
Psych
Additional Comments:

4. History & Physical template June 2016 by K. Sherman Pg. 4 of 4
Patient Name: ____________________________
Date of Service: ___________________________
SKETCH OF INJURY/PROBLEM AREA/PROPOSED TREATMENT
ASSESSMENT/PLAN WITH DIAGNOSES
______________________________________________ ________________ __________________
First name, Last name MD Date Time