102 HISTORY AND PHYSICAL SHORT FORM

Dr. Luis Cuadros 505.243.7670


Pt name: ________________________________________ DOB: _______________

CSN: _______________________________

Date of Admission: _______________________

Allergies: ______________________

 

ADMITTING DIAGNOSIS: ________________________

 

PROCEDURE(S) PLANNED: _______________________

 

HISTORY OF PRESENT ILLNESS:

 

MEDICATIONS:

 

PAST SURGICAL HISTORY:

 

PAST SIGNIFICANT MEDICAL HISTORY:

 

REVIEW OF SYSTEMS:

 

HABITS: ETOH

               SMOKING

 

PHYSICAL EXAMINATION:

VITAL SIGNS: TEMP BP HR

 

HEAD and NECK:

            HEENT anicteric, PERRLA

 

CHEST: Lungs clear, cor regular

 

ABDOMEN: benign no masses or abnormality

 

PELVIC AND RECTAL: deferred

 

EXTREMITIES: normal