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HISTORY AND PHYSICAL COLLECTED BY :
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PRESENTING COMPLAINT
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HPI
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PREGNANT?
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FAINTING WITH NEEDLES/SHOTS?
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ALLERGIES
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ALLERGIES (OTHER)
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EMERGENCY CONTACT
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EMERGENCY CONTACT PHONE #
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PAST MEDICAL HISTORY
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OTHER MEDICAL PROBLEMS
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SURGICAL HISTORY
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Complete list of surgeries
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MEDICATIONS
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SUPPLEMENTS
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Childhood illnesses
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Comments
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Childhood Immunizations
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Comments
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PCP Contact Information
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PCP NAME
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STRESSORS SECTION:
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Does the patient smoke?
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If yes, please specify ppd
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Does the patient drink alcohol?
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If yes, please mention drinks per day/week
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Does the patient use drugs?
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Comments
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Does the patient eat wheat/ gluten?
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Comments
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Do you consume Soda?
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Comments
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Does the patient eat dairy?
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Comments
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Does the patient eat sweets?
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Comments
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Does the patient eat fried foods?
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Comments
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HEAVY METALS AND TOXINS EXPOSURE
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Comments
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ANTIBIOTICS:
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# OF ROUNDS LIFETIME
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Does the patient have mercury silver amalgams?
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RELATIONSHIP STRESS:
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TRAUMA:
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WorkStatus
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Number of hours worked per week
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Occupation
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STRESS RELIEF SECTION
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Sleep: Average hrs/ night ?
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how long
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Does patient exercise?
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MOVEMENT
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PRAYER / MEDITATION
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QUIET TIME
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PHYSICAL EXAM
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General WNL
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General Abnormal
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General Comments
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HEENT WNL
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HEENT Abnormal
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HEENT Comments
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Skin WNL
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Skin Lesion
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Skin Comments
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Neck WNL
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Neck Abnormal
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Neck Comments
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Cardiovascular WNL
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Cardiovascular Abnormal
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Cardiovascular Comments
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Lungs WNL
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Lungs Abnormal
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Lungs Comments
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Abdomen WNL
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Abdomen Abnormal
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Abdomen Comments
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MSK WNL
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MSK Abnormal
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MSK Comments
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Breasts WNL
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Breasts Abnormal
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Breasts Comments
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Neuro WNL
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Neuro Abnormal
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Neuro Comments
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Extremities WNL
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Extrem Abnormal
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Extrem Comments
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LABS
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ASSESSMENT AND PLAN
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PROBLEM LIST - ASSESSMENET
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Plan
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