Patient Encounter Form Page 3

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CHEST:
*Respiratory Effort
Normal
Abnormal
*Ausculation
Normal
Abnormal
*Percussion
Normal
Abnormal
*Palpation
Normal
Abnormal
CARDIOVASCULAR
*Palpation
Normal
Abnormal
*Auscultation
Normal
Abnormal
EXAMINATION OF:
*Carotid
Normal
Abnormal
*Femoral
Normal
Abnormal
*Pedal
Normal
Abnormal
*Para aortic
Normal
Abnormal
*Edema
Normal
Abnormal
*Varicosity
Normal
Abnormal
BREASTS:
* Symmetry
Normal
Abnormal
Discharge
NO
YES
* Masses
NO
YES
Tenderness
NO
YES
ABDOMEN:
* Masses
NO
YES
Tenderness
NO
YES
* Hepatosplenomegaly
NO
YES
* Hernia
NO
YES
*
Normal
Abnormal
Anus/perineum/rectum
* Guiac
Negative
Positive
N/A
* Bowel Sounds
Normal
Abnormal
GU/ PELVIC EXAM:
Cervical Pap Performed Yes
No
Other Pap: Where____________________________
* Vulva
Normal
Abnormal
Vagina
Normal
Abnormal
* Urethra
Normal
Abnormal
* Bladder
Normal
Abnormal
3

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