PATIENT NAME: ________________
COMPREHENSIVE HISTORY & PHYSICAL EXAM
DATE: __________; TIME__________
Identifying Information:
Gender: M/F; Age: _____; Occupation: __________; Marital Status: S/M/Dating/Divorced
Source of History: Self / Other __________; Referral: Y/N; Reliability of History: __________ (Memory; Trust; Mood)
History of Present Illness:
Chief Complaint #1: (1) Location: __________; (2) Quality: Burning / Cramping / Electric Shock / Other __________;
(3) Quantity/Severity: ___/10; (4) Timing (Onset/Duration/Frequency): ________________________________________;
(5) Setting: ____________________; (6) Aggravating / Alleviating: ________________________________________;
(7) Associated Manifestations: _____________________________________________________________________________
(8) Additional Information: ________________________________________________________________________________
Chief Complaint #2: (1) Location: __________; (2) Quality: Burning / Cramping / Electric Shock / Other __________;
(3) Quantity/Severity: ___/10; (4) Timing (Onset/Duration/Frequency): ________________________________________;
(5) Setting: ____________________; (6) Aggravating / Alleviating: ________________________________________;
(7) Associated Manifestations: _____________________________________________________________________________
(8) Additional Information: ________________________________________________________________________________
Medications:
Med #1: Name__________; Route: Oral / IM; Dose & Frequency _________; Purpose _________
Med #2: Name__________; Route: Oral / IM; Dose & Frequency _________; Purpose _________
Med #3: Name__________; Route: Oral / IM; Dose & Frequency _________; Purpose _________
Med #4: Name__________; Route: Oral / IM; Dose & Frequency _________; Purpose _________
Home Remedies: __________________; Vitamins/Minerals: __________________; Contraceptives: __________________
Allergies
Allergy 1: __________________; Reaction: Rash / Anaphylaxis / Other ______
Allergy 2: __________________; Reaction: Rash / Anaphylaxis / Other ______
Past History
Childhood Illnesses (and age): Chickenpox __ yrs; Measles __ yrs; Rubella __ yrs; Mumps __ yrs; Whooping Cough __ yrs;
Rheumatic Fever __ yrs; Scarlet Rever __ yrs; Polio __ yrs
Adult:
Medical: Diabetes / Heart Disease / Hypertension / Hepatitis / Asthma / HIV
Hospitalizations: ________________________________________________________________________________
Surgical (Dates / Indications / Types of Operations): ____________________________________________________
OBGYN (Obstetric / Menstrual History / Methods of Contraception / Sexual Function): ________________________
Psychiatric (Illness and time frame / diagnoses / hospitalizations / tx): ________________________________________
Preventative:
Immunizations: Tetanus ____; Pertussis ____; Diphtheria ____; Polio ____; MMR: ____; Influenza ____;
Varicella/Zoster ____; Hepatitis B ____; H. Influenza Type B ____; Pneumococcal ____;
Screening: EKG ______; Colonoscopy____; Tuberculin ____; Pap Smears ____; Mammograms ____; Stool Occult ____;
Blood Tests: Cholesterol ____;
Family History (Relationship / Age of Diagnosis / Current Age)
Heart: Hypertension________; CAD ________; Cholesterol ________; Stroke ________; Diabetes ________;
Cancer: ____________________ (colon/breast/ovarian/prostate)
Thyroid / Renal Disease: ____________; Arthritis ________; Tuberculosis ________; Asthma / Lung Disease ________;
Mental Illness: ___________; Suicide ___________; Substance Abuse ________; Allergies ________; Genetic Diseases
_______
Personal and Social History:
Eduction Level ________; Occupation ________; Stress ________; Current Household _________; Financial _______;
Personal Interests: ____________; Retirement _______________; Religious Affiliations / Spiritual Beliefs ___________
Exercise: ____________________; Diet: ____________________; Dietary Supplements / Restrictions ___________________
Caffein: ______________;
Safety Measures (seat belt, helmets, sunblock, smoke detectors: ____________________
Sexual Practices (number of partners, safe sex practices): ________________________
Drug Use:
Review of Systems:
General: recent weight change / weakness / fatigue / fever
Skin: Rashes / lumps / sores / itching / dryness / changes in color / changes in hair or nails / changes in size or color of moles
HEENT:
COMPREHENSIVE HISTORY & PHYSICAL EXAM
Head: Headache / head injury / dizziness / lightheadedness
Eyes: Vision / glasses, contacts / last exam _____ / pain / redness / excessive tearing / double or blurred vision / spots, specks /
flashing lights / glaucoma / cataracts
Ears: Hearing / tinnitus / vertigo / earaches / infection / discharge
Nose and sinuses: frequent colds / nasal stuffiness/ discharge / itching / hay fever / nosebleeds / sinus trouble
Throat (mouth / pharynx): Condition of teeth and gums / bleeding gums / dentures / last dental exam ___ / sore tongue / dry
mouth / frequent sore throats / hoarseness
Neck: Swollen glands; goiter; lumps; pain; stiffness in neck
Breasts: Lumps; pain; discomfort; nipple discharge; self-examination practices
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