SUBJECTIVE: NEW PATIENT HISTORY

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CHIEF COMPLAINT: initial visit to establish primary care.

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HPI:

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PMH (problem list):

|PROBLEM LIST- TAMPA|

H/O:

HTN [ ] YES [ ] NO

Cardiovascular Dz [ ] YES [ ] NO

TB/positive PPD [ ] YES [ ] NO

PUD [ ] YES [ ] NO

Depression [ ] YES [ ] NO

Anxiety [ ] YES [ ] NO

PTSD [ ] YES [ ] NO

Hepatitis [ ] YES [ ] NO

Cancer [ ] YES [ ] NO

MOST RECENT TESTS:

Colonoscopy - [ ] YES [ ] NO

Stress Test - [ ] YES [ ] NO

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|DISABILITIES/SC (HS)|

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Medications:

|ACTIVE MEDS BY PT STATUS|

|REMOTE ACTIVE MEDICATIONS|

|EXPIRED OP MEDS;180|

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[ ] ALLERGY/ADVERSE REACTIONS, confirmed by patient:|ALLERGIES/ADR|

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PAST SURGICAL Hx:

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FAMILY HISTORY - Patient was asked about a family history of:

Mother:

Father:

Siblings:

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SOCIAL HISTORY:

Alcohol use: [ ] daily [ ] ocassionally [ ] rarely

[ ] beers [ ] liquor

Illicit (street) drugs ever used? [ ] YES [ ] NO

Any IV Drug use? [ ] YES [ ] NO

Last time illicit drugs used (if applicable)?

Type: [ ] Cannaboids [ ] Cocaine [ ] Heroin

[ ] Methadone [ ] Opiates

Tobacco use: [ ] NEVER

Current [ ] YES [ ] NO Year Quit:

Type - [ ] Cigarettes [ ] Cigars [ ] Pipe [ ] Smokeless

Usage -

Martial Status:

Living arrangements:

Functional Status:

Exercise type/frequency: [ ] None [ ] yes

Employment:[ ] Retired [ ] Full/part time [ ] Unemployed [ ] student

-Occupation:

MILITARY HISTORY:

BRANCH OF SERVICE: [ ] Army [ ] Marines [ ] Air Force

[ ] Navy [ ] Coast Guard

Combat veteran? [ ] YES [ ] NO

Environmental Exposure: [ ] YES [ ] NO

Duties/occupation:

OUTSIDE RECORDS REVIEWED/AVAILABLE: [ ] YES [ ] NO

PRIVATE PHYSICIAN(S): [ ] None [ ] yes:

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REVIEW OF SYSTEMS: per HPI [x]yes [ ]No

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Gen: [ ] fevers [ ] night sweats. [ ] weight changes

Eyes: [ ] vision changes

Ears: [ ] hearing changes

Mouth: [ ] dysphagia

Pulm: [ ] dyspnea [ ]PND [ ] cough

CV: [ ] chest pain [ ] palpitations [ ]edema

GI: [ ] n/v/d [ ] melena [ ]hematochezia

GU: [ ] dysuria. [ ]flank pain [ ] hematuria

MSK: [ ]muscle pain [ ] joint pains

SKIn: [ ] new rashes

NEURO: [ ] numbnes [ ] tingling [ ]focal weakness or slurred speech. [ ]headache

PSYCH: [ ]suicidal ideations [ ]depression [ ]anxiety [ ]sleeping problem

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PHYSICAL EXAM:

VITALS (most recent, as listed in the electronic record):

B/P: |BLOOD PRESSURE|

Pulse: |PULSE|

RR: |RESPIRATION|

Temperature: |TEMPERATURE|

Height: |PATIENT HEIGHT|

BMI: |BMI|

Pain: |PAIN| (0-10 scale)

Weight history - Most recent three weights:

|WEIGHT HISTORY|

APPEARANCE: [ ]Well Developed, well nourished [ ]Obese

[ ]No acute distress

HEAD: [ ]NC/AT

EYES: [ ]PERRL [ ]EOMI [ ]no scleral icterii

NECK: [ ]No masses palpable

[ ]No bruits appreciated

[ ]FROM

LUNGS: [ ]CTA [ ]no wheezes [ ]no rhonchi

[ ]decreased breath sounds bilaterally

CARDIOVASCULAR:

RHYTHM: [ ]regular [ ]normal s1 s2

AUSCULTATION: [ ]no murmur appreciated [ ]murmur

ABDOMEN: [ ]soft [ ]nontender

[ ]normal bowel sounds

BACK: [ ]non-tender spine [ ]full range of motion

SKELETAL: [ ]shoulder [ ]knee

LOWER EXTREMITIES: (indicated by "X")

Edema - [ ]YES [ ]NO

Cyanosis - [ ]YES [ ]NO

Pulses - [ ]2+ [ ]1+/trace [ ]nonpalpable

Microfilament exam -[ ]

SKIN: [ ]no rash

DRE: [ ]declines/defers

NEURO: [ ]no focal deficits [ ]good muscle bulk/tone

PSYCH: [ ]normal mood and affect [ ]calm and cooperative

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LABS:

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|CBC (2 OCC)|

|BMP/1 OCC 30D (HS)|

|HEPATIC PANEL/1 OCC 3M (HS)|

|HGBA1C 2OCC 1YR (HS)|

|LIPID CLINIC (HS)|

|PSA(HS)|

{FLD:X BOX} no recent or new labs to discuss today

{FLD:X BOX} lab results discussed with patient today

{FLD:X BOX} labs drawn results pending

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ASSESSMENT/PLAN:

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FOLLOW UP: [ ] week(s) [ ] month(s) & RTC P.R.N. with

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Immunizations: |IMMUNIZATIONS (HS)|

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