H&P is to be completed within 30 days of the procedure/admit 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with the 'Chief Complaint/History of Present Illness' section. Clearly state the patient's primary concern and any relevant history.
3. In the 'Meds/Dosages/Frequency' field, list all medications the patient is currently taking, including dosages and frequency.
4. Document any known allergies in the designated area, ensuring to include reactions if applicable.
5. Fill out the 'Smoking/Drugs/Alcohol' section with relevant details about the patient's habits.
6. Complete the 'Anesth/Surg Complications' field by noting any past complications related to anesthesia or surgeries.
7. Provide a thorough account of family and social history, as well as past medical/surgical history, checking off any relevant conditions listed.
8. Conduct a physical examination and check off normal findings or provide comments where necessary in each body system section.
9. Conclude with a diagnosis/impression and planned treatment/procedure before signing and dating the document.

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