Physical Examination on a Person that is 18 years Older

1. complete physical examination that will be performed on a person that is 18 years old or older.
2. Submit a typed SOAP Note of the 18years old physical assessment. Make sure to follow the proper sequential order in your physical assessment and use the correct terminology in your SOAP Note.

SOAP Note Template

 

Encounter date:  ________________________

 

Patient Initials: ______ Gender: M/F/Transgender ____  Age:  _____ Race: _____ Ethnicity ____

 

 

Reason for Seeking Health Care: ______________________________________________

 

HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________

Current perception of Health:         Excellent     Good     Fair   Poor

Past Medical History

• Major/Chronic Illnesses____________________________________________________
• Trauma/Injury ___________________________________________________________
• Hospitalizations __________________________________________________________

Past Surgical History___________________________________________________________

Medications: __________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

Family History:  ____________________________________________________________

 

 

Social history:

Lives: Single family House/Condo/ with stairs: ___________  Marital Status:________  Employment Status: ______ Current/Previous occupation type: _________________

Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________

Sexual orientation: _______ Sexual Activity: ____ Contraception Use: ____________

Family Composition: Family/Mother/Father/Alone: _____________________________

Health Maintenance

Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____

Exposures:

Immunization HX:

 

Review of Systems:

General:

HEENT:

Neck:

Lungs:

Cardiovascular:

Breast:

GI:

Male/female genital:

GU:

Neuro:

Musculoskeletal:

Activity & Exercise:

Psychosocial:

Derm:

Nutrition:

Sleep/Rest:

LMP:

STI Hx:

 

Physical Exam

 

BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt.   ______ BMI (percentile) _____

General:

HEENT:

Neck:

Pulmonary:

Cardiovascular:

Breast:

GI:

Male/female genital:

GU:

Neuro:

Musculoskeletal:

Derm:

Psychosocial:

Misc.

 

 

 

 

 

 

Plan:

Differential Diagnoses

1.

2.

3.

Principal Diagnoses

1.

2.

Plan

Diagnosis

Diagnostic Testing:

Pharmacological Treatment:

Education:

Referrals:

Follow-up:

Anticipatory Guidance:

 

Diagnosis

Diagnostic Testing:

Pharmacological Treatment:

Education:

Referrals:

Follow-up:

Anticipatory Guidance:

 

 

 

Signature (with appropriate credentials): __________________________________________

 

Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________

 

 

 

 

 

 

 

DEA#:  101010101                          STU Clinic                                   LIC# 10000000

                                                      

Tel: (000) 555-1234                                                                             FAX: (000) 555-12222

 

Patient Name: (Initials)______________________________        Age ___________

Date: _______________

RX ______________________________________

SIG:

Dispense:  ___________                                                     Refill: _________________

        No Substitution

Signature: ____________________________________________________________

1. complete physical examination that will be performed on a person that is 18 years old or older.
2. Submit a typed SOAP Note of the 18years old physical assessment. Make sure to follow the proper sequential order in your physical assessment and use the correct terminology in your SOAP Note.

SOAP Note Template

 

Encounter date:  ________________________

 

Patient Initials: ______ Gender: M/F/Transgender ____  Age:  _____ Race: _____ Ethnicity ____

 

 

Reason for Seeking Health Care: ______________________________________________

 

HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________

Current perception of Health:         Excellent     Good     Fair   Poor

Past Medical History

• Major/Chronic Illnesses____________________________________________________
• Trauma/Injury ___________________________________________________________
• Hospitalizations __________________________________________________________

Past Surgical History___________________________________________________________

Medications: __________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

Family History:  ____________________________________________________________

 

 

Social history:

Lives: Single family House/Condo/ with stairs: ___________  Marital Status:________  Employment Status: ______ Current/Previous occupation type: _________________

Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________

Sexual orientation: _______ Sexual Activity: ____ Contraception Use: ____________

Family Composition: Family/Mother/Father/Alone: _____________________________

Health Maintenance

Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____

Exposures:

Immunization HX:

 

Review of Systems:

General:

HEENT:

Neck:

Lungs:

Cardiovascular:

Breast:

GI:

Male/female genital:

GU:

Neuro:

Musculoskeletal:

Activity & Exercise:

Psychosocial:

Derm:

Nutrition:

Sleep/Rest:

LMP:

STI Hx:

 

Physical Exam

 

BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt.   ______ BMI (percentile) _____

General:

HEENT:

Neck:

Pulmonary:

Cardiovascular:

Breast:

GI:

Male/female genital:

GU:

Neuro:

Musculoskeletal:

Derm:

Psychosocial:

Misc.

 

 

 

 

 

 

Plan:

Differential Diagnoses

1.

2.

3.

Principal Diagnoses

1.

2.

Plan

Diagnosis

Diagnostic Testing:

Pharmacological Treatment:

Education:

Referrals:

Follow-up:

Anticipatory Guidance:

 

Diagnosis

Diagnostic Testing:

Pharmacological Treatment:

Education:

Referrals:

Follow-up:

Anticipatory Guidance:

 

 

 

Signature (with appropriate credentials): __________________________________________

 

Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________

 

 

 

 

 

 

 

DEA#:  101010101                          STU Clinic                                   LIC# 10000000

                                                      

Tel: (000) 555-1234                                                                             FAX: (000) 555-12222

 

Patient Name: (Initials)______________________________        Age ___________

Date: _______________

RX ______________________________________

SIG:

Dispense:  ___________                                                     Refill: _________________

        No Substitution

Signature: ____________________________________________________________

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