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Date: Referring Physician: Address: Reason for consult/Visit: Initial Visit Year/ Month / Week / Post-op Follow up Age Right / Left Handed Vitals: B/P / P R T WT HT Allergies: Meds: see med sheet Nurse's Signature: History Form dated today was reviewed with patient. No Changes OR Changes in ROS and/or PFSH are as follows: Chief Complaint: HP1: Context: Quality: Duration: Associated signs/symptoms: Severity: Timing: Modifying factors: Location: Service:
PHSx:
Full Range Of Motion: flexion extension, rotation, ateral bend Kyphosis Scoliosis
EYES: (system) Discs flat, no hemorrhages or exudates noted. CARD: (system) No Carotid bruits. RRR. no murmurs. No peripheral edema, no varicosities. skin warm MUSCULO: (system) Full range of motion of joints Muscle strength with full resistance to opposition in upper and lower extremities. Firm muscle tone, w/o spasticity, atrophy or abnormal movements in upper and lower extremities.
PSYCH: (system) Pleasant. Appropriate. Alert and oriented x 3 RESP: (system) Respiration non-labored Clear to auscultation bilaterally
SKIN: (system) Clear, no wounds, rashes lesions or ulcers Wounds well healed GAIT: (system) Coordinated and smooth Slow with limp on R / L Able to Heel/Toe walk
Motor: DF PF LE R L
Prob. Focused = 1 body area/org. system Exp. Prob. Focused = 2org. systems (including affected body areas) Detailed = 5 org. systems (including affected body area) Comp = 8 org. systems Additional Exam Comments:
No
IMPRESSION:
Resident/Fellow: Date: Teaching/Attending Physician Comments regarding History, &/or Exam, &/or Decision Making:
SEE DICTATION
Attending:
Date: