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Exam Template

Contents (below)
  • Adult Exam: Comprehensive History

  • Adult Exam: Comprehensive History

    I. Goals

    II. Introduction

    A. age, weight (child), ethnicity, social

    III. HPI

    IV. Allergies and Sensitivities

    V. Medications

    VI. Environment/Exposures

    VII. Genetic

    family history: CA (breast, GI, skin), DM, IHD, depression, suicide, psychosis, glaucoma, hypertension

    VIII. Medical History

    IX. Psychosocial

    1. job, family, schooling, hobby, sexual
    2. relationships, violence, abuse

    X. ROS

    general: fever, weight changes, sleep changes, energy level
    endocrine: thyroid, diabetes
    neurological/psychiatric: dizziness/vertigo, sensory changes, memory, mood, anxiety
    skin: nails, pigmented lesions, hair loss
    heent: hearing, vision, rhinitis, dental, thyroid, swallowing
    breast: self-exam
    cardiovascular: apnea, snoring, sleep disturbance, claudication
    GI: gas, hematochezia, melena, hemorrhoids, constipation
    GU: incontinence, hesitancy, frequency
    Gyne: menstrual history, last PAP, contraception

    Author: John G. Faughnan.  The views and opinions expressed in this page are strictly those of the page author. Pages are updated on an irregular schedule; suggestions/fixes are welcome but they may take weeks to years to be incorporated. Anyone may freely link to anything on this site and print any page; no permission is needed for citing, linking,  printing, or distributing printed copies.