Select a client, family member, or friend to interview for a complete health history and complete a physical examination.

Description

History and Physical Template

Select a client, family member, or friend to interview for a complete health history and complete a physical examination. Only use the individual’s initials when referring to the client.

Subjective (History): 27 points

I. Identifying Data

II. Chief Complaint (CC)

III. History of Present Illness (HPI)

IV. Past Medical History (PMH)

A. Hospitalizations

B. Surgeries

C. Medications

D. Allergies

V. Family History

VI. Social History

VII. Review of Systems

A. General

B. Skin

C. HEENT

D. Neck

E. Cardiovascular

F. Respiratory

G. Gastrointestinal

H. Genitourinary

I. Musculoskeletal

J. Neurological

K. Mental Health

Objective (Physical) 27 points

I. Constitutional: Vital Signs, General appearance, initial impression

II. Skin

III. Eyes

IV. Ears, Nose, Throat/Neck

V. Cardiovascular

VI. Pulmonary

VII. Abdomen

VIII. Musculoskeletal

IX. Neurological

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