Please Complete the Following Information

Patient Label

Today’s Date: _____ / _____/ _____ Age: ______Family Doctor: ______LEP: Interpreter ______Please complete the following information: What is the main reason for your visit today?

Are you having any problems or symptoms today that you would like to discuss?  yes  no If you answered yes, please briefly explain: Are you allergic to any medicines or foods?  yes  no If you answered yes, please list what medicines or foods you are allergic to and your reaction to each:

Current medications (Prescription / Over the counter):  None  Multivitamins  Calcium  Birth Control______ Other: Since your last visit, have you had any hospitalizations, major injuries, or surgeries?  yes  no If you answered yes, please briefly explain: Since your last visit, please check if there have there been major health changes for the following: Patient (you) Parent  Sister/ Brother Child Grandparent None Please describe any changes: Since your last visit, please check if you have had major changes in the following: Educational Status Employment status Marital status Living conditions None Please describe any changes: Nutrition: check foods you eat every Do you have concerns about Exercise day your weight? Yes  None  Seldom Milk / Dairy Meats Vegetables No  Occasional  Frequent Fruits Breads or Grains Tobacco Use / Smoke Alcohol Street Drugs Mental Health: (in past 90 Exposure None None days)  Never used  Exposed to Seldom: type Seldom: type  No Problem smoke ______ Mild/Moderate Depression  Past user: type Occasional: type Occasional: type  Severe Depression ______ Anxiety Use now: type Frequent: type Frequent: type Thoughts of harming self / ______others (# per day _____) Dental Health Water Source: Travel: No travel outside Brush daily Floss daily  Well  Cistern USA Traveled outside USA: Visit dentist every 6 months  Bottled  City Country/Year______/_____ Abuse / Neglect / Violence: Sexually Active with:  not Females only: Do you examine  No fear of harm Pressure sexually active your breasts every month? Yes to have sex Males Females  Both No Daily needs not met Forced sexual Number of partners: First day of last menstrual period: contact in past month ____ in past 2 ______/______/______Fear of verbal/physical abuse months ____ Sex for money or drugs in past 12 months ______Reproductive Life Plan: Do you have any children?  yes  no Do you want more children?  yes  no If yes, how many more children do you want to have and when? ______Patient Signature: Date: TO BE COMPLETED BY HEALTHCARE PROVIDER Immunization Status:  Up to date by patient report Lead Assessment:  Records Requested Verbal Risk Assessment: neg  pos NA  See Vaccine Administration Record Tested Today:  yes  no  Vaccines given today Referred for testing:  yes  no Preventive Health Education: topics discussed today Educational

pg. 1 H&P 14 Adult (06/17)  Child development  Physical activity  Preconception /Folic Acid  Pelvic / Handouts: Pap  FPEM  PTEM  Immunizations  Safety  Prenatal / Genetics  SBE  CSEM  Other: /Mammogram  Dental  Mental Health  CVD  STE / PSA Patient Verbalizes  Hearing/Vision  DV/SA  Arthritis  HRT Understanding of  Lead exposure (ACH-25a)  ATOD / Cessation / SHS  Osteoporosis Education given   STD / HIV  Diet / Nutrition  Diabetes  Cancer  Reproductive Life Plan  Options Counseling  MINOR Family Planning: Sexual coercion. Abstinence. Benefits of parental involvement.

Healthcare Provider Signature: Date:

SUBJECTIVE / PRESENTING PROBLEM:

OBJECTIVE: General Multi-System Examination SYSTEM WNL ABNORMAL SYSTEM WNL ABNORMAL General appearance Lymphatic Neck, Axilla, Constitution Groin al Nutritional status Spine Vital signs Musculoskele ROM Head: Fontanels, tal Symmetry Scalp Eyes: PERRL Inspection(rash Skin / SQ es) Conjunctivae, lids Tissue Palpation (nodules) HEENT Ear: Canals, Drums Reflexes Neurological Hearing Sensation Nose: Mucosa/ Orientation Septum Psychiatric Mouth: Lips, Palate Mood / Affect Teeth, Gums EXPLANATION OF ABNORMAL FINDINGS: Throat: Tonsils Overall appearance Neck Thyroid Respiratory effort Respiratory Lungs Heart Cardiovascu Femoral/Pedal lar pulses Extremities Thorax Chest Nipples Breasts Abdomen Gastro- Tanner Stage:  typical  atypical Liver / Spleen intestinal Anus / Perineum X-Ray: Type: Result: Male: Scrotum Date taken:No Change Testes Date read: Neg/Non-remarkable Penis Date compared with: Improved Worsening Genitourinar y

Prostate Female:Genitalia Patient Label

Vagina TB Classification:  TB suspect Cervix 0 No TB exposure, not infected Uterus I TB exposure, no evidence of infection Adnexa II TB infection, without disease III TB, clinically active IV TB, not clinically active Site of infection: Pulmonary __Cavity __Non Cavity  Other: ASSESSMENT:

Testing today:  N/A Medications/Supplies: Recommendations made to client, Referrals made:  N/A  GC /Chlamydia urine  N/A for scheduling of follow-up testing  PCP/Medical Home  GC/Chlamydia swab  MV / Folic Acid and  Pediatrician  UA  TST Number of bottles procedures, based on assessment:  WIC  VDRL  HIV  Hep given_____  N/A  Specialist: C  Birth Control Method  Vision  Hearing  FBS  FP  Pap Lead ______/GTT  Radiology   Hgb  Cholesterol  Given  Rx  Dental  Lipid Screen Medicaid  Blood Glucose  Foam Issued (#) ______ Hgb  MNT with RD  HANDS  Urine PT / UCG: Pos  Condoms Issued (#)  Pap Smear  Sickle Cell  Lead  Social Services Neg Planned ______ Mammogram  Ultrasound   1-800-QUIT-NOW pregnancy?  Yes  No  Foam/Condoms offered; Other:  Freedom from Smoking Wet Mount pt. declined  UCG/HCG  TST / CXR  Other: Other:   Other: Bone Density  Liver Panel Blood Glucose  Colorectal Scr. Ovarian Cancer Scr. : Healthcare Provider Signature: Date: Recommended RTC:

pg. 3 H&P 14 Adult (Rev. 06/17)