MULTIDISCIPLINARY ADMISSION HISTORY AND PHYSICAL ASSESSMENT PART I: TO BE COMPLETED BY PHYSICIAN OR OTHER HEALTHCARE PROVIDERS WHERE SPECIFIED Primary

Language: ________________________ Interpreter Used: No Yes CHIEF COMPLAINT: HISTORY OF THE PRESENT ILLNESS: Name: _______________________

Is there any possibility this patient could be pregnant: Yes (LMP: ___/___/_____ ) No N/A PAST MEDICAL/SURGICAL/OBSTETRICAL/PSYCHIATRIC HISTORY:

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MEDICATIONS:
Dose or Freq Reason Medication (include herbals and OTC meds) Dose Route Freq if PRN unknown (check here) Ordered on admission? YES NO If omitted, please state reason why. (e.g. NPO, formulary change, undesired side effect, hemodynamically unstable, etc.)

Source of medication information: Patient Family Old chart Pharmacy ALLERGIES: NONE Drugs/food/latex/contrast/other: 1) 2) 3) 4) 5) SOCIAL HISTORY: Reaction:

PCP

Sending Facility Other: ______

FAMILY HISTORY:

Tobacco history: Never Previous (quit: ______) Current smoker Amount: ____packs/day for ____ years Is patient interested in quitting? Yes No If yes, see smoking cessation program orderset Alcohol consumption history: History of withdrawal: No Yes If yes, describe: ________________________ Illicit drug consumption history: REVIEW OF SYSTEMS: COMMENT Eyes Neg Pos Not Done Ears/Nose/Mouth/Throat Neg Pos Not Done Cardiovascular Neg Pos Not Done Gastrointestinal Neg Pos Not Done Respiratory Neg Pos Not Done Musculoskeletal Neg Pos Not Done Integumentary Neg Pos Not Done Neurologic Neg Pos Not Done Endocrinologic Neg Pos Not Done Psychiatric Neg Pos Not Done Hematologic/Lymphatic Neg Pos Not Done Not Done Genitourinary Neg Pos Page 2 of 4

PHYSICAL EXAMINATION VITAL SIGNS: T: ______ BP: ______ 1. General appearance: 2. Head/Eyes/Ears/Nose/Throat: 3. Neck: 4. Heart: 5. Lungs/Chest: 6. Abdomen: 7. Extremities/Back: 8. Skin: 9. Neurologic: Pulse: ______ RR: _____ O2 Sat: _____% O2: ____L/min Wt ______ Ht _____

10. Pulses: 11. Lymphatic: 12. Rectal exam: 13. Pelvic/GU exam: Declined Declined Not done Not done

Laboratories/Studies: UA: CXR: ECG:

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ASSESSMENT & PLAN:

____/____/_____ @ _____:_____ Provider Signature Print Name & Credentials Beeper #/ID Date & Time ATTENDING NOTE: I have personally seen and examined the patient and reviewed with ______________________________ the history & physical examination, laboratory data and studies, and proposed management. My findings include:

I have informed Dr. __________________________ (PCP or designee) Provider Signature Print Name & Credentials Beeper #/ID ____/____/_____ @ _____:_____ Date & Time

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