Abstraction Encounter Form
ADVERTISEMENT
1
2
31
Abstraction Encounter Form
SUFFOLK SURGICAL ASSOCIATES, PC
D
:
P
N
:
DOB:
ATE
ATIENT
AME
Vitals: (last visit)
Date
BP
Pulse
Resp.
Temp
Sp02______
Weight
Height _________
Allergies: (include: Type/Reaction)
Medications:
Name
Dose
Route
How often or times per day:
(If sig is unknown look on Database instead of preference list)
Medical History:
** list date of onset next to condition **
□
□
□
Allergies
Depression
Myocardial infarction
□
□
□
Anemia
Diabetes mellitus
Nerve/muscle disease
□
□
□
Anxiety
Emphysema
Osteoporosis
□
□
□
Arthritis
GERD
Seizures
□
□
□
Asthma
Glaucoma
Sickle cell anemia
□
□
□
Blood transfusion
Heart murmur
Stroke
□
□
□
Cancer
HIV/AIDS
Substance abuse
□
□
□
Cataracts
Hypertension
Thyroid disease
□
□
□
CHF
Kidney disease
Tuberculosis
□
□
□
Clotting disorder
Meningitis
Ulcers
□
□
□
COPD
Rheumatic Fever
STD
□
□
□
hemorrhoids
Pancreatitis
A-Fib
Coronary artery
□
□
disease
Hyperlipidemia
Additional Medical History:
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical