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  • Name: Age: Race: Gender: Referral: Date:
    White | Black | Hispanic | Asian | Male | Female
  • Gen impression: alert | not in distress | well groomed | disheveled | distressed | in resp distress | relaxed | thin | obese | energetic | lethargic
  • CC:
  • Source and reliability all normal | omit all
    • Source: self | omit | other
    • Reliability: reliable | omit | other
  • HPI:
  • ROS
    • General no to all | yes to all | omit all
      • weight loss: no | yes | omit | notes
      • fever: no | yes | omit | notes
      • chills: no | yes | omit | notes
      • sweats: no | yes | omit | notes
      • anorexia: no | yes | omit | notes
      • fatigue: no | yes | omit | notes
      • malaise: no | yes | omit | notes
    • Skin no to all | yes to all | omit all
      • rashes: no | yes | omit | notes
      • lesions: no | yes | omit | notes
      • itching: no | yes | omit | notes
      • dryness: no | yes | omit | notes
      • sweating: no | yes | omit | notes
    • HEENT
      • Head no to all | yes to all | omit all
        • headache: no | yes | omit | notes
        • head trauma: no | yes | omit | notes
        • hair loss: no | yes | omit | notes
      • Eyes no to all | yes to all | omit all
        • glasses: no | yes | omit | notes
        • vision problems: no | yes | omit | notes
        • eye discomfort: no | yes | omit | notes
        • eye discharge: no | yes | omit | notes
        • photophobia: no | yes | omit | notes
      • Ears no to all | yes to all | omit all
        • earache: no | yes | omit | notes
        • ear discharge: no | yes | omit | notes
        • vertigo: no | yes | omit | notes
        • hearing problems: no | yes | omit | notes
        • tinnitus: no | yes | omit | notes
      • Nose no to all | yes to all | omit all
        • congestion: no | yes | omit | notes
        • nosebleeds: no | yes | omit | notes
      • Throat no to all | yes to all | omit all
        • sore throat: no | yes | omit | notes
        • hoarseness: no | yes | omit | notes
        • dysphagia: no | yes | omit | notes
        • odynophagia: no | yes | omit | notes
    • Neck no to all | yes to all | omit all
      • neck lumps: no | yes | omit | notes
      • neck pain: no | yes | omit | notes
    • Breast no to all | yes to all | omit all
      • breast lumps: no | yes | omit | notes
      • breast pain: no | yes | omit | notes
      • nipple discharge: no | yes | omit | notes
    • Respiratory no to all | yes to all | omit all
      • cough: no | yes | omit | notes
      • sputum: no | yes | omit | notes
      • hemoptysis: no | yes | omit | notes
      • dyspnea: no | yes | omit | notes
      • wheezing: no | yes | omit | notes
    • Cardiovascular no to all | yes to all | omit all
      • chest discomfort: no | yes | omit | notes
      • palpitations: no | yes | omit | notes
      • dyspnea: no | yes | omit | notes
      • orthopnea: no | yes | omit | notes
      • PND: no | yes | omit | notes
      • syncope: no | yes | omit | notes
      • edema: no | yes | omit | notes
    • Gastrointestinal no to all | yes to all | omit all
      • abdominal pain: no | yes | omit | notes
      • nausea: no | yes | omit | notes
      • vomiting: no | yes | omit | notes
      • diarrhea: no | yes | omit | notes
      • constipation: no | yes | omit | notes
      • bowel habit changes: no | yes | omit | notes
      • jaundice: no | yes | omit | notes
      • vomiting blood: no | yes | omit | notes
      • blood in stool: no | yes | omit | notes
      • tarry stools: no | yes | omit | notes
    • Genitourinary no to all | yes to all | omit all
      • painful urination: no | yes | omit | notes
      • GU discharge: no | yes | omit | notes
      • hematuria: no | yes | omit | notes
      • flank pain: no | yes | omit | notes
      • frequent urination: no | yes | omit | notes
      • nocturia: no | yes | omit | notes
      • incontinence: no | yes | omit | notes
      • hesitancy: no | yes | omit | notes
      • difficulty urinating: no | yes | omit | notes
    • Male genital no to all | yes to all | omit all
      • testicular pain: no | yes | omit | notes
      • testicular lumps: no | yes | omit | notes
      • genital pain: no | yes | omit | notes
      • genital lesions: no | yes | omit | notes
    • Female genital no to all | yes to all | omit all
      • amenorrhea: no | yes | omit | notes
      • dysmenorrhea: no | yes | omit | notes
      • menorrhagia: no | yes | omit | notes
      • vaginal bleeding: no | yes | omit | notes
      • pelvic pain: no | yes | omit | notes
      • genital pain: no | yes | omit | notes
      • genital lesions: no | yes | omit | notes
    • Musculoskeletal no to all | yes to all | omit all
      • back pain: no | yes | omit | notes
      • joint pain: no | yes | omit | notes
      • joint swelling: no | yes | omit | notes
      • muscle pain: no | yes | omit | notes
      • muscle weakness: no | yes | omit | notes
      • stiffness: no | yes | omit | notes
    • Psychiatric no to all | yes to all | omit all
      • depression: no | yes | omit | notes
      • suicidal ideation: no | yes | omit | notes
      • memory loss: no | yes | omit | notes
      • mental disturbances: no | yes | omit | notes
      • hallucinations: no | yes | omit | notes
      • anxiety: no | yes | omit | notes
      • paranoia: no | yes | omit | notes
    • Neurologic no to all | yes to all | omit all
      • weakness: no | yes | omit | notes
      • paresis: no | yes | omit | notes
      • paralysis: no | yes | omit | notes
      • numbness/tingling: no | yes | omit | notes
      • sensory loss: no | yes | omit | notes
      • tremors: no | yes | omit | notes
      • seizures: no | yes | omit | notes
      • syncope: no | yes | omit | notes
      • dizziness: no | yes | omit | notes
      • memory loss: no | yes | omit | notes
    • Hematologic no to all | yes to all | omit all
      • easy bruising: no | yes | omit | notes
      • easy bleeding: no | yes | omit | notes
      • lymphadenopathy: no | yes | omit | notes
    • Endocrine no to all | yes to all | omit all
      • cold intolerance: no | yes | omit | notes
      • heat intolerance: no | yes | omit | notes
      • sweating: no | yes | omit | notes
      • excesive thirst: no | yes | omit | notes
      • excessive hunger: no | yes | omit | notes
      • excessive urination: no | yes | omit | notes
      • weight changes: no | yes | omit | notes
  • PMH:
  • Family History:
  • Social History:
  • Medications:
  • Allergies:
  • Vitals:
    • Height (ft, in) | Height (cm)
    • Weight (lb) | Weight (kg)
    • BMI calculate BMI
    • Blood pressure
    • Heart rate
    • Respiratory rate
    • Temperature (F) | Temperature (C) calculate other unit
    • O2 sat
  • Physical exam
    • Skin all normal | omit all
      • Color: pink | omit | other
      • Feel: warm and dry | omit | other
      • Appearance: no rashes or lesions | omit | other
      • Nails: no clubbing or cyanosis | omit | other
    • HEENT
      • Head all normal | omit all
        • Head: normocephalic/atraumatic | omit | other
        • Hair: average texture | omit | other
      • Eyes all normal | omit all
        • Visual acuity: 20/20 bilaterally | omit | other
        • Visual fields: full | omit | other
        • Sclera: white | omit | other
        • Conjunctiva: pink | omit | other
        • Pupils: normal size and bilaterally equal, round and reactive to light and accommodation
          | omit | other
        • Funduscopic: disc margins sharp, no hemorrhages or exudates, no arteriolar narrowing
          | omit | other
      • Ears all normal | omit all
        • Acuity: good to rubbing of the fingers | omit | other
        • Tympanic membrane: clear with cone of light | omit | other
        • Weber: midline | omit | other
        • Rinne: AC > BC | omit | other
      • Nose all normal | omit all
        • Nasal mucosa: pink | omit | other
        • Nasal septum: midline | omit | other
        • Sinus: nontender | omit | other
      • Throat all normal | omit all
        • Oral mucosa: pink, without lesions | omit | other
        • Gums and teeth: good gums and dentition | omit | other
        • Pharynx: without exudates | omit | other
        • Tongue: midline, average size | omit | other
    • Neck all normal | omit all
      • Trachea: midline | omit | other
      • Neck: supple | omit | other
      • Thyroid: isthmus palpable, lobes not felt | omit | other
    • Lymph nodes all normal | omit all
      • Cervical: nontender, nonpalpable | omit | other
      • Axillary: nontender, nonpalpable | omit | other
      • Epitrochlear: nontender, nonpalpable | omit | other
      • Inguinal: nontender, nonpalpable | omit | other
    • Pulmonary and thorax all normal | omit all
      • Thorax inspection: symmetric with good excursion | omit | other
      • Thorax palpation: nontender | omit | other
      • Lung percussion: resonant | omit | other
      • Lung auscultation: breath sounds vesicular, no rales, wheezes, or rhonchi
        | omit | other
    • Cardiovascular all normal | omit all
      • Cardio inspection: JVP nonelevated, no visible heaves | omit | other
      • Cardio palpation: chest nontender, PMI tapping, no heaves or thrills, carotid upstrokes brisk
        | omit | other
      • Cardio auscultation: S1, S2, no murmurs or extra heart sounds, no carotid bruits
        | omit | other
    • Peripheral vascular all normal | omit all
      • Pulses: radial, brachial, femoral, popliteal, dorsalis pedis, posterior tibial pulses are 2+ and symmetric
        | omit | other
      • Calves: no redness, tenderness or swelling | omit | other
      • Extremities: pink, warm, without edema | omit | other
      • Vascular auscultation: no femoral or abdominal bruits | omit | other
    • Abdominal all normal | omit all
      • Abdominal inspection: normal contour, no scars, striae, or varicosities
        | omit | other
      • Abdominal auscultation: audible bowel sounds, no aortic, renal, iliac, or femoral bruits
        | omit | other
      • Abdominal palpation: soft, nontender, no masses felt | omit | other
      • Liver: nontender, size normal | omit | other
      • Spleen: nontender, nonpalpable | omit | other
      • Kidneys: no CVA tenderness, no flank mass | omit | other
    • Musculoskeletal all normal | omit all
      • Joints: no deformities | omit | other
      • Range of motion: full in the hands, wrists, elbows, shoulders, neck, spine, hips, knees, and ankles
        | omit | other
    • Neurologic all normal | omit all
      • Mental status: alert and cooperative | omit | other
      • Cranial nerves: CN I not tested, CN II-XII intact | omit | other
      • Motor: good muscle bulk and tone, strength 5/5 throughout
        | omit | other
      • Reflexes: biceps, triceps, patellar, achilles reflexes are 2+ and bilateral, downward plantar
        | omit | other
      • Sensory: pain, light touch, position and vibration intact
        | omit | other
      • Cerebellar: rapid alternating movements, finger-to-nose, heel-to-shin intact, gait steady
        | omit | other
    • Male genital all normal | omit all
      • Foreskin: prepuce easily retractible | omit | other
      • Penis: without lesions or discharge | omit | other
      • Testes: no masses or tenderness | omit | other
    • Male rectal all normal | omit all
      • Perirectal: no lesions | omit | other
      • External sphincter: tone intact | omit | other
      • Rectum: no masses | omit | other
      • Prostate: smooth, nontender | omit | other
      • Stool: brown, negative for occult blood | omit | other
    • Breast all normal | omit all
      • Breast inspection: symmetric, no visible masses, retractions or dimpling
        | omit | other
      • Breast palpation: nontender, no masses felt, nipples without discharge
        | omit | other
    • Female genital all normal | omit all
      • External genitalia: no lesions or inguinal lymphadenopathy | omit | other
      • Vagina: mucosa pink | omit | other
      • Cervix: smooth, pink, without discharge | omit | other
      • Uterus: midline, nontender, size normal | omit | other
      • Ovaries: no adnexal tenderness or mass | omit | other
    • Female rectal all normal | omit all
      • Perirectal: no lesions | omit | other
      • External sphincter: tone intact | omit | other
      • Rectum: no masses | omit | other
      • Stool: brown, negative for occult blood | omit | other
  • Labs:
  • Problem list:
  • Assessment and Plan:
Generate: Full write up | SOAP note | Select all

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