Sample History and Physical and Consultation Report
Social History: Smoking _____. Drinking _____. Drugs _____.
Allergy: _____.
Medication: _____.
Prior Illness: _____.
Prior Surgery: _____.
Prior Cardiac Testing: _____.
Family History: _____.
History of Present Illness: _____.
Review of Systems: _____.
Physical Exam: No complaints.
1. General: _____.
2. Vital Signs: _____.
3. HEENT: _____.
4. Heart: _____.
5. Chest: _____.
6. Abdomen: _____.
7. Extremity: _____.
8. Neurology: _____.
Diagnostic Data:
1. Hematology: _____.
2. Chemistry: _____.
3. Cardiac Marker: _____.
4. Bacteriology: _____.
5. EKG/Echo: _____.
6. X-rays: _____.
Assessment:
1. _____.
2. _____.
3. _____.
Plan:
1. _____.
2. _____.
3. _____.
