Northern Kentucky University

MSN 610: Diagnostic Reasoning and Advanced Physical Assessment

 

Comprehensive History & Physical Exam

DEMOGRAPHICS

 

Providers Name: ___________________________________ Patient’s Initials: (Data Source)____________________

 

Date of Exam: _____________________________________ Patient’s DOB/AGE: _______________

 

Chief Complaint: ____________________________________   Gender/Sexual Orientation: ____________________

 

History of Present Illness:

 

 

 

 

 

 

Past Medical History:

 

              Active Problems:

 

 

              Resolved Problems:

                              

 

Previous Hospitalizations:

 

 

Surgical History:

 

 

Allergies:

 

Current Medications:

 

 

 

Social History:

              Living Arrangements:

 

              Occupation:

 

              Environmental Safety:

 

              Smoking:

 

              Alcohol:

 

              Drugs:

 

              Diet:

 

              Other Non-Prescribed Drugs:

 

 

Family History:

 

Relationship Living or Deceased Age Illnesses

 

 

Preventative Health/ Anticipatory Guidance: (Age Appropriate)

 

1.       Safety Issues:

 

2.       Screenings:

 

3.       Immunizations:

 

Reproductive health:

 

 

Review of Systems:

 

General:

 

Skin, Hair, Nails:

 

HEENT:

 

Neck:

 

Cardiovascular:

 

Pulmonary:

 

Abd/GI:

 

Genitourinary/ Gynecology/ Breast:

 

Musculoskeletal:

 

Neuro:

 

Endo/Lymphatic:

 

Hematology:

 

Psych:

 

 

 

 

 

 

Physical Exam

 

Vital Signs:           Temp: __________   Pulse: _______    BP:   _________/________  Resp: ______         O2 sat: _________

 

General:
Head:
Ears:
Eyes:
Nose:
Throat:
Neck:

 

 

 

 

 

Assessment Statement: 

 

 

 

 

Problem List (As many or as few as needed)

Include ICD – 10 CODE

 

1.

 

2.

 

3.

 

 

 

 

Plan:

 

1.

 

2.

 

3.

 

4.

 

 

Submitted by: __________________________________________________

Date: __________________________________________

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