Id Consult Template

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STAMP
402 MR
SMH
University of Rochester
Strong Memorial Hospital
Highland Hospital
Inpatient
Outpatient
ED
INFECTIOUS DISEASES
CONSULTATION
DATE:_____________ TIME:______________ Consult requested by Dr.________________________________
Consulted for: ____________________________________________________________________________
History of Presenting Illness:
History from:  Patient  Family  Med record
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PMHx
SOCIAL HX
ROS
N Y
N Y
Neg Pos
Wt loss, fatigue, fever ______
DM______________________
Tobacco________
ENT___________________
Cancer _____________________
Alcohol_________
ESRD____________________
Ilicit drugs_______
Eye____________________
Other:
Travel___________
Resp___________________
Animals: _________
CV____________________
Occupation:____________
GI: ____________________
Other:
GU: ___________________
Skin: __________________
Lymph: ________________
Mus-skel: _______________
FAMILY HX
Neuro: _________________
Not relevant to current dx
Pysch: _________________
N Y
Endo: __________________
TB___________________
ROS
neg except as noted above & HPI
other signif ID_________
PMH, FH, SH, ROS unobtainable
Level 4-5 consult: 10+ ROS, or ROS neg
due to:
Other:
except as noted; PE 8+ systems; FH + SH
+ PMH (or document unobtainable)

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