Rm _________ Name _____________________________ A/S _______ DOB _____________ MRN __________________

Significant Hx CC: Imaging & Tests

Story

ROS Medications: Social Hx.

Constitutional: No Weight Change, No Fever, No Chills, No Night Sweats, No Fatigue
ENT/Mouth: No Hearing Changes, No Ear Pain, No Nasal Congestion, No Sinus Pain,
No Hoarseness, No sore throat, No Rhinorrhea, No Swallowing Difficulty
Eyes: No Eye Pain, No Swelling, No Redness, No Discharge, No Vision Changes Assessment & Plan
Cardiovascular: No Chest Pain, No SOB, No PND, No Dyspnea on Exertion,
No Orthopnea, No Claudication, No Edema, No Palpitations
Respiratory: No Cough, No Sputum, No Wheezing, No Dyspnea Surgical Hx.
Gastrointestinal: No Nausea, No Vomiting, No Diarrhea, No Constipation, No Pain,
No Heartburn, No Anorexia, No Dysphagia, No Hematochezia, No Melena,
No Flatulence, No Jaundice
Genitourinary: No Dysmenorrhea, No DUB, No Dyspareunia, No Dysuria,
No Urinary Frequency, No Hematuria, No Urinary Incontinence, No Urgency,
Musculoskeletal: No Arthralgias, No Myalgias, No Joint Swelling, No Joint Stiffness, Fam Hx.
No Back Pain, No Neck Pain, No Injury History
Skin: No Skin Lesions, No Pruritis, No Hair Changes, No Breast/Skin Change,
Neuro: No Weakness, No Numbness, No Paresthesias, No Loss of Consciousness,
No Syncope, No Dizziness, No Headache, No Coordination Changes, No Recent Falls
No Social Issues, No Memory Changes, No Violence/Abuse Hx., No Eating Concerns Allergies
Heme/Lymph: No Bruising, No Bleeding, No Transfusions hx, No Lymphadenopathy
Endocrine: No Polyuria, No Polydipsia, No Temperature Intolerance

General: Heart:

Skin & Lymph: Abdomen:

HEENT: Extremities:

Neck: Neuro:

Lungs: Other: