<p>INITIAL REFUGEE VISIT TO FAMILY MEDICINE CLINIC</p><p>HPI Interpreter: ***</p><p>@NAME@ is a @AGE@ @SEX@ refugee from *** who arrived to the US in *** and presents for an initial visit to establish care. </p><p>ROS: As per HPI {and all other systems negative}</p><p>History Patient's medications, allergies, past medical, surgical, social and family histories were reviewed and updated as appropriate.</p><p>@ALLERGY@</p><p>@MED@</p><p>@MEDICALHX@</p><p>@SURGICALHX@</p><p>Social History Country of origin: Country of exit: Date of arrival in Charlottesville (U.S.): First Language: Second Language: Literate? Years spent in Refugee camp: {NUMBERS (6/7/96, TDB):22879} Marital status:{IS MARRIED/HAS BEEN MARRIED:2100200217} Children: Lives with: Education: Religion: Traditional remedies: Work history: Trauma/Violence: Smoking/ETOH:</p><p>Overseas Records Date: RPR: Vision: CXR:</p><p>Health Dept Records Date: TST: Chest x-ray: {NORMAL/ABNORMAL ONLY:20759} RPR: HIV: HbSAg U/A: Stool specimen results: Symptomatic (Diarrhea)?: Hgb: Vaccines given: Concerns:</p><p>***CUT AND PASTE ABOVE SOCIAL HX TO SOCIAL HISTORY TAB***</p><p>Objective: Physical Exam @VS@ CONSTITUTIONAL: Well-developed *** in no acute distress HEENT: Normocephalic/atraumatic. EOM intact. Moist mucous membranes, no obvious oral lesions NECK: Supple, no anterior cervical or supraclavicular lymphadenopathy CARDIO: Normal rate, regular rhythm, no murmurs/rubs/gallops PULM: Lungs clear to auscultation bilaterally, normal effort, no signs of respiratory distress GI: Abdomen is soft, non-tender, non-distended, with normal bowel sounds present MSK: No clubbing, cyanosis, or edema. No obvious joint deformities SKIN: Skin is warm and dry. No rash noted. NEURO: Alert, follows commands, answers questions appropriately, no gross deficits PSYCH: Pleasant affect</p><p>Assessment/Plan:</p><p>@NAME@ is a @AGE@ @SEX@ who presents today for @CHIEFCOMPLAINT@.</p><p>@DIAGMED@</p><p>@FOLLOWUP@</p><p>The patient was discussed with Dr. *** who is in agreement with the findings and plan as discussed above. </p><p>International Family Medicine Clinic Database Information Sheet Reason for Visit: Initial Visit Date of service: @TD@ Name: @NAME@ MRN# @MRN@ DOB: @DOB@ Gender: @SEX@ ------Date of Arrival (C'ville):</p><p>Country of Origin:</p><p>Country of Exit: </p><p>Primary Language: </p><p>Secondary Language:</p><p>Does the patient speak English? [ ] Yes [ ] No If yes, does patient: [ ] speak it [ ] write it [ ] both</p><p>Did patient have a prior Health Department screening? [ ] Yes [ ] No [ ] Not Applicable If yes, date screened? </p><p>Is patient alone in country or accompanied by family? </p><p>Referral from: [ ] IRC [ ] Hospital/Other provider [ ] School [ ] Health Dept [ ] Self-referral [ ] UVA Emergency Dept [ ] Other (specify) ______</p><p>------Interpreter Needed? [ ] Yes [ ] No If Yes, was an interpreter present? [ ] Professional Present [ ] Not Present [ ] Cyracom Phone [ ] Provider [ ] Professional Dismissed [ ] Family/Friend If present, was Interpreter from: [ ] Hospital [ ] IRC [ ] Other (specify) [ ] Harrisonburg AHEC</p><p>Diagnoses for this visit: @DIAGX@ Provider: @ME@ </p><p>General Disposition: [ ] IFMC [ ] Specialty Clinic [ ] Both Mental Health Disposition: [ ] IFMC [ ] Fam Stress Clinic [ ] Other International Family Medicine Clinic Database Information Sheet Reason for Visit: Follow Up Date of service: @TD@ Name: @NAME@ MRN# @MRN@ DOB: @DOB@ Gender: @SEX@ </p><p>Interpreter Needed? {Blank multiple:19196::"Yes"} If Yes, was an interpreter present? [ ] Professional Present [ ] Not Present [ ] Cyracom Phone [ ] Provider [ ] Professional Dismissed [ ] Family/Friend If present, was Interpreter from: [ ] Hospital [ ] IRC [ ] Other (specify) [ ] Harrisonburg AHEC</p><p>Diagnoses for this visit: @DIAGREFRESH@ Provider: @ME@ General Disposition: [ ] IFMC [ ] Specialty Clinic [ ] Both Mental Health Disposition: [ ] IFMC [ ] Fam Stress Clinic [ ] Other</p>