Comprehensive History  Physical Template

Chief Complaint:

History of Present Illness:
- Onset/Location/Duration:
- Characteristics:
- Aggravating/Relieving Factors:
- Associated Symptoms:

Past Medical History:
- Medical Conditions:
- Surgical History:
- Hospitalizations:
- Immunizations:

Medications:
- Prescription:
- OTC/Supplements:

Allergies:
- Drug:
- Food/Environmental:
- Reactions:

Family History:

Social History:
- Occupation:
- Living Situation:
- Tobacco/Alcohol/Substances:

Review of Systems:
- Constitutional:
- HEENT:
- Cardiovascular:
- Respiratory:
- GI/GU:
- Neuro/Psych:
- Endocrine/Heme:

Physical Exam:
- Vital Signs:
- General Appearance:
- HEENT:
- Cardiovascular:
- Respiratory:
- Abdomen:
- Extremities:
- Neuro:

Diagnostics:
- Labs Ordered/Reviewed:
- Imaging:

Assessment:
- Primary Diagnosis:
- Differential Diagnoses:

Plan:
- Diagnostics:
- Medications/Therapies:
- Consults/Referrals:
- Patient Education:
- Follow-up:

Sign-off:
- Provider Signature  Credentials
- Date / Time