HISTORY OF PRESENT ILLNESS:

{FLD:ALLFT47/200}

{FLD:ALLFT47/200}

|PROBLEM LIST COMMENTS|

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|DISABILITIES/SC (HS)|

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ALLERGY/ADVERSE REACTIONS (as displayed in Vista): |ALLERGIES/ADR|

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CURRENT MEDICATIONS:

|ACTIVE MEDS BY PT STATUS|

|REMOTE ACTIVE MEDICATIONS|

|EXPIRED OP MEDS;180|

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SOCIAL HISTORY:

Alcohol use: {FLD:00 YES/NO} {FLD:0-10 BOX}{FLD:DAY/WK/MON} {FLD:ADDITIONAL COMMENTS (TEXT)}{FLD:00 EDIT BOX 24}

Illicit (street) drugs used recently? {FLD:00 YES/NO} {FLD:ADDITIONAL COMMENTS (TEXT)}{FLD:00 EDIT BOX 24}

Tobacco use:{FLD:SMOKE}{FLD:0-10 BOX}PP {FLD:DAY/WK/MON} Year Quit:{FLD:DATE}

Social status: {FLD:ALLMARTIALSTATUS4} {FLD:TBI/POLY VOCATIONAL STATUS} {FLD:ADDITIONAL COMMENTS (TEXT)}{FLD:00 EDIT BOX 24}

Exercise type/frequency: {FLD:00 YES/NO}, {FLD:ADDITIONAL COMMENTS (TEXT)}{FLD:00 EDIT BOX 24}

OUTSIDE RECORDS REVIEWED/AVAILABLE: {FLD:00 YES/NO}

PRIVATE PHYSICIAN(S): {FLD:00 YES/NO} {FLD:ADDITIONAL COMMENTS (TEXT)}{FLD:00 EDIT BOX 24}

DST Tool Reviewed: {FLD:X BOX}Eligible {FLD:X BOX}Not Eligible

Patient's preference: {FLD:X BOX}Opt-in for CC {FLD:X BOX}Opt-out for CC

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REVIEW OF SYSTEMS: per HPI

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{FLD:X BOX}No involuntary weight loss, fatigue

{FLD:X BOX}No chest pain, shortness of breath, palpitations or dizziness

{FLD:X BOX}No urinary problems

{FLD:X BOX}No bowel problems

{FLD:X BOX}No SI/HI

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PHYSICAL EXAMINATION

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

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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: {FLD:X BOX}Well Developed, well nourished {FLD:X BOX}Obese

{FLD:X BOX}No acute distress

HEAD: {FLD:X BOX}NC/AT

EYES: {FLD:X BOX}PERRL {FLD:X BOX}EOMI {FLD:X BOX}no scleral icterii

NECK: {FLD:X BOX}No masses palpable

{FLD:X BOX}No bruits appreciated

{FLD:X BOX}FROM

LUNGS: {FLD:X BOX}CTA {FLD:X BOX}no wheezes {FLD:X BOX}no rhonchi

{FLD:X BOX}decreased breath sounds bilaterally

CARDIOVASCULAR:

RHYTHM: {FLD:X BOX}regular {FLD:X BOX}normal s1 s2

AUSCULTATION: {FLD:X BOX}no murmur appreciated {FLD:X BOX}murmur

ABDOMEN: {FLD:X BOX}soft {FLD:X BOX}nontender

{FLD:X BOX}normal bowel sounds

BACK: {FLD:X BOX}non-tender spine {FLD:X BOX}full range of motion

SKELETAL: {FLD:X BOX}shoulder {FLD:X BOX}knee

LOWER EXTREMITIES: (indicated by "X")

Edema - {FLD:X BOX}YES {FLD:X BOX}NO

Cyanosis - {FLD:X BOX}YES {FLD:X BOX}NO

Pulses - {FLD:X BOX}2+ {FLD:X BOX}1+/trace {FLD:X BOX}nonpalpable

Microfilament exam -{FLD:X BOX}

SKIN: {FLD:X BOX}no rash

DRE: {FLD:X BOX}declines/defers

NEURO: {FLD:X BOX}no focal deficits {FLD:X BOX}good muscle bulk/tone

PSYCH: {FLD:X BOX}normal mood and affect {FLD:X BOX}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

{FLD:X BOX} SEND TO LABS

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ASSESSMENTS/PLANS:

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{FLD:ALLFT47/200}

{FLD:ALLFT47/200}

{FLD:ALLFT47/200}

{FLD:ALLFT47/200}

|PAST EYE APPT 2Y|

RETURN TO CLINIC: [12 ] MONTHS + [x ] LABS

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

[ x] Assesment and plan discussed and explained to patient in detail.

Patient given opportunity to ask questions and those were answered.

Patient expressed agreement and understanding of the diagnoses and

treatment plan.

[x ] Patient reminded of our advanced access policy, and understands he

can call for an appointment or even walk in to be seen in ER or urgent care

anytime, in case of urgent need, in addition to his regular follow up

appointment/s.

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PREVENTIVE MEDICINE / CLINICAL REMINDERS:

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Immunizations: |IMMUNIZATIONS (HS)|