Patient Encounter Form Page 2
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7TO BE COMPLETED BY PHYSICIAN
5. History of Present Illness (1-3 breif; 4+ extended):
REVIEW OF SYSTEMS
6.
Constitutional
Muscular
Eyes
Neurological
Skin/Breast
Genitourinary
Ears, Nose and Throat
Endocrine
Gastrointestinal
Mental Status
Chest
Immunology
Cardiovascular
Hematology/Lymph
Office Use:
ROS - 1 problem pertinent
2-9 extended
10+ complete
EXAM
CONSTITUTIONAL:
*General:
BP
Pulse
Height
Weight
*Appearance:
Appropriate for age___________ Cachectic
Underweight________________ Overweight
EYES
*Conjunctivae and lids
Normal
Abnormal
*Pupils and Irises:
Pupils Equal
Abnormal
Round/Reactive
Abnormal
Light/ Accom.
Abnormal
*Ophthalmoscopic exam
Normal
Abnormal
EARS/ NOSE/ MOUTH/ THROAT:
*
Ears
Normal
Abnormal
Nose
Normal
Abnormal
*Otoscopic Exam
Normal
Abnormal
*Hearing Assessment
Normal
Abnormal
*Nasal Mucosa, Septum
Normal
Abnormal
*Lips, teeth, gums
Normal
Abnormal
*Oropharynx Exam
Normal
Abnormal
NECK:
*Neck
Normal
Abnormal
*Thyromegaly
Absent
Present
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Parent category: Medical