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Prescription Medications Medication Dose/Number per Day Non-Prescription Medications Patient Name Drug Allergies /Type of Reaction No known drug allergies Latex Tape Social History Please check the appropriate listings Tobacco Use Never Quit/When Cigarettes/Pack per Day Pipe Cigars Chewing Tobacco How many years Alcohol Use Socially Daily Heavy Drug Use Marijuana Amphetamines Other Exercise 1-2x/week 3-4x/week 5-7x/week Caffeine Use Occasional Have you ever been treated for alcoholism Yes No If ...

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What is the purpose of a history and physical exam?

The History and Physical Exam, often called the "H&P" is the starting point of the patient's "story" as to why they sought medical attention or are now receiving medical attention.

What needs to be included in a history and physical?

Required elements of a complete H&P are: Chief complaint, details of present illness, relevant past history appropriate to the patient's age, drugs, allergies, assessment of body system (including heart and lungs), conclusion/impression, and plan of care.

What are the 4 components of medical history?

A medical record is a systematic documentation of a patient's medical history and care. It usually contains the patient's health information (PHI) which includes identification information, health history, medical examination findings and billing information.

What does a history and physical include?

Contents of a History and Physical Examination (H&P) 2. The H&P shall consist of chief complaint, history of present illness, allergies and medications, relevant social and family history, past medical history, review of systems and physical examination, appropriate to the patient's age.

What is included in a history and physical?

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What is the purpose of health history and physical assessment?

A complete history and physical examination can identify important health issues that may be solved at the domestic medical examination visit or more chronic conditions that need further evaluation or management.

How do you write a present medical history for a patient?

It should include some or all of the following elements: Location: What is the location of the pain? Quality: Include a description of the quality of the symptom (i.e. sharp pain) Severity: Degree of pain for example can be described on a scale of 1 - 10. Duration: How long have you had the pain.

What are the components of the focused history and physical exam?

In documenting a focused history and performing a focused physical examination, you need to explore the chief complaint, the history of the present illness, the past medical history, medications and allergies, the family history and social history, the occupational history, and the sexual history that are relevant to ...

What is usually included in a physical?

Elements of a Physical Exam A thorough physical examination covers head to toe and usually lasts about 30 minutes. It measures important vital signs -- temperature, blood pressure, and heart rate -- and evaluates your body using observation, palpitation, percussion, and auscultation.

What is a history and physical exam?

The H&P: History and Physical is the most formal and complete assessment of the patient and the problem. H&P is shorthand for the formal document that physicians produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending.

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