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UPPER RESPIRATORY SYMPTOMS

SPANGDAHLEM AIR FORCE BASE


Location of Medical Records: Fam Prac 52nd 752nd 852nd
Date ____________ ________________
________________
Time____________
Work Phone______ PCM:
________________
Home Phone______
S: _____ y/o male/female c/o UPPER RESPIRATORY SYMPTOMS for ______ days.
________________
Subjective Exclusion Criteria for URI Nurse Managed Clinic:
PRP Yes/No Book appointment for patient if any positive response.
Wt______________ Y/N SOB/Wheezing/Orthopnea
Y/N Newly swollen ankles or legs
Ht______________ Y/N Severe difficulty in swallowing
T_______________ Y/N Unable to eat or drink
Y/N Ear Pain
R_______________ Y/N Hx of Asthma
BP______________ Y/N Fever greater than 100.5 for five days or more
Y/N Symptoms for more than two weeks
P_______________ Y/N Brown or bloody sputum
Pulse Ox: _______% Yes/No Thick, discolored nasal discharge
Pain? Y/N Yes/No Clear watery nasal discharge Yes/No Pain over sinus areas and upper teeth
Yes/No Body aches Yes/No Pain worsens with bending over
If Yes, rate 1-10: Yes/No Headache Yes/No Post nasal drip
Complaint Yes/No Cough (dry / productive) Yes/No Sore throat
Yes/No Producing ________ phlegm Yes/No Tender, swollen lymph nodes
Deployment Yes/No Sneezing Yes/No Nausea / Vomiting (x ______)
Related? Y/N Yes/No Itchy eyes, nose, or throat Yes/No Urinary symptoms
Yes/No Ill contacts Yes/No Diarrhea (x______)
PHA: ___________
Tob Y/N PMH:
Type____________ Yes/No Allergy problems
Qty_____________ Yes/No Sinus problems
Freq____________ Home Treatment Tried:______________________________________________________________
ETOH Y/N
Type____________ O: Nurse Managed Clinic – Physical Exam Deferred
Qty_____________
Freq____________ General: ___________________________________________________________________________
Allergies: Sinuses: Maxillary: nontender tender
________________ Frontal: nontender tender
Medications: Ears: Canals: Clear Cerumen Drainage Red
________________ TMs: Intact Perforated
________________ Shiny Dull
Gray Red
Mobile Nonmobile
- / + Fluid level
NAME
 HISTORY & PHYSICAL  OPERATION REPORT
EXAMINATION (SF 516)
(SF 504, SF 505, & SF
506)
REGISTER NO. SSN
 CONSULTATION SHEET  NARRATIVE SUMMARY
(SF-513) (SF 502)
STATUS
 CHRON RECORD OF  AUTOPSY PROTOCOL
MEDICAL CARE - (SF (SF 503)
600)
DATE TIME
 PROGRESS NOTE  EMG REPORT
(SF 509)

Computer Rev. Jun 94 MEDICAL RECORD REPORT OPTIONAL FORM 275 (12 77)
Prescribed by GSA
FPMR (41 CFR) 10
UPPER RESPIRATORY SYMPTOMS
SPANGDAHLEM AIR FORCE BASE
Location of Medical Records: Fam Prac 52nd 752nd 852nd
Nares:
Clear
Red
Pale
Edematous
Boggy
Dis
charge:
clear /
purulent
Throat:
Pink
Red
Edematous

Exudate

Tonsillar
size: ___/4
Symmetric:
Y/N
Uvula
midline: Y/N
Neck:
Supple
-/+
Lymphadenopathy
(anterior / posterior /
cervical)
Lungs:
CTA
Other:
_________________
_________________
______________
Heart:
RRR
No murmur
Other:
_________________
_________________

NAME
 HISTORY & PHYSICAL  OPERATION REPORT
EXAMINATION (SF 516)
(SF 504, SF 505, & SF
506)
REGISTER NO. SSN
 CONSULTATION SHEET  NARRATIVE SUMMARY
(SF-513) (SF 502)
STATUS
 CHRON RECORD OF  AUTOPSY PROTOCOL
MEDICAL CARE - (SF (SF 503)
600)
DATE TIME
 PROGRESS NOTE  EMG REPORT
(SF 509)

Computer Rev. Jun 94 MEDICAL RECORD REPORT OPTIONAL FORM 275 (12 77)
Prescribed by GSA