History And Physical Form PDF Details

Physicians have been using the history and physical form (H&P) for years to help them diagnose their patients. The form is a summary of a patient's medical history and current condition, which can help physicians identify potential problems early on. While the H&P may seem like a simple document, there's actually quite a bit of detail that goes into compiling it correctly. In this blog post, we'll take a closer look at the history and physical form and discuss some of the key components that make it so important. We'll also provide some tips on how to create an accurate H&P for your patients.

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QuestionAnswer
Form NameHistory And Physical Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesprintable blank h p template, history and physical exam template, physical history and template, inpatient history physical sample

Form Preview Example

Inpatient History & Physical Form

Patient Stamp

 

Internal Medicine

 

 

Greenville Hospital System

 

 

( ) Initial Visit

( ) Consult requested by:

 

 

Date:

Service:

NAME:

AGE:

1º MD:

Attending:

MRN:

ROOM#:

 

 

Chief Complaint/Reason for Consult:

Allergies:

History of Present Illness:

Medications and Dosages:

Past Medical/Surgical History:

Social History:

Family History:

Page 1 of 4

Comprehensive Review of Systems

ROS NOT OBTAINABLE BECAUSE

Patient Stamp

Constitutional:

 

Genitourinary:

 

YES NO

DESCRIBE

YES NO

DESCRIBE

Fever, sweats or chills

 

Dysuria, frequency or urgency

 

Menstrual irregularities

 

Fatigue, anorexia, weight loss or gain

 

LMP ___________________

Weakness

 

 

Frequent UTI’s

 

 

 

 

 

 

Pain/Hematuria

 

Skin:

 

Musculoskelatal:

Rashes, no skin breakdown

 

Muscle aches, arthralgias or arthritis

 

 

 

 

 

Neurologic:

 

 

Mental status changes

Head:

 

 

Headaches

Headache

 

 

Dizziness

Visual changes

 

 

Weakness or numbness

Earache, sinus problems, sore throat

 

 

Seizures

Cough, snoring or mouth ulcers

 

 

Ataxia

 

 

 

 

Hematopoietic:

 

 

Lymphadenopathy

 

 

Bleeding tendencies

 

 

 

Cardiovascular:

 

Psychiatric:

Chest pain or palpitations

 

History of anxiety or depression

Syncope

 

Hallucinations/Delusions

Edema

 

 

 

 

 

 

 

Endocrine:

 

 

History of diabetes

 

 

History of thyroid problems

 

 

 

 

 

Other Symptoms:

Respiratory:

 

 

Shortness of breath

 

 

Cough or sputum production

 

 

Dyspnea on exertion orthopnea

 

 

Pleuritic chest pain

 

 

 

 

 

Gastrointestinal:

 

 

Heartburn, dysphagia

 

 

Nausea or vomiting

 

 

Diarrhea or constipation

 

 

Melena or BRBPR

 

 

Hematemesis

 

 

Abdominal pain

 

 

Page 2 of 4

Patient Stamp

Physical Exam

 

 

Labs and Studies

Vitals:

 

 

 

CBC:

 

Wt:

Temp:

BP:

P:

 

 

HT:

Resp:

Sat:

 

 

 

Constitutional:

nl general appearance

 

 

 

 

 

 

 

 

 

Head:

 

Normo-cephalic/atraumatic

 

BMP:

 

 

 

PERRLA

 

 

 

 

 

EOMI

 

 

 

 

 

nl sclera

 

 

 

 

 

Vision

 

 

 

Ears, Nose, Mouth & Throat:

 

CXR:

 

 

 

nl inspection of nasal

 

 

 

 

 

mucosa, septum, turbinates,

 

 

 

 

teeth, gums & oropharynx

 

 

 

 

nl ear canal and T

 

 

 

 

 

 

 

 

 

Neck:

 

nl neck appearance &

 

EKG:

 

 

 

jugular veins

 

 

 

 

 

Thyroid not palpable, non-tender

 

 

 

 

 

 

 

 

Lymph Nodes

 

nl neck, supraclavicular

 

 

 

 

 

or axillary adenopathy

 

 

 

 

 

 

 

 

Skin/Extremities:

Rashes, lesions or ulcers

 

 

 

 

 

Digits & nails

 

 

 

 

 

Edema

 

 

 

Breast Evaluation:

No skin changes

 

 

 

 

 

No nipple discharge

 

 

 

 

 

No lumps/masses

 

 

 

 

 

Fibrocystic changes

 

 

 

Respiratory:

 

Chest symmetric, nl chest

 

 

 

 

Expansion & respiratory effort

 

 

 

 

nl auscultation

 

 

 

 

 

nl chest percussion &

 

 

 

 

 

palpation

 

 

 

Cardiovascular:

Reg rhythm

 

 

 

 

 

No murmur, gallop or rub

 

 

 

 

Periph vasc no by ovserv &

 

 

 

 

palpation

 

 

 

Gastrointestinal:

No tenderness or masses

 

 

 

 

 

Liver & spleen not felt

 

 

 

 

 

nl bowel sounds

 

 

 

 

 

Heme negative stool

 

 

 

Musculoskeletal:

nl muscle strength, movement &

Neurologic:

Alert and oriented

 

 

tone, no focal atrophy

 

 

nl reflexes upper and lower

 

 

nl gait & station

 

 

extremities

 

 

 

 

 

Cranial nerves intact

Genito-urinary:

no pelvic exam

 

Psychiatric:

 

 

 

nl testes

 

 

nl mood/affect

Page 3of 4

Patient Stamp

Assessment:

Plan:

Attending HPI:

Attending PE:

Attending Assessment and Plan:

Resident signature:

MD

PGY1, PGY2, PGY3 Date:

Pager:

/1439

Resident name printed:

Dictated by:

Intern Pager:

/1872

Attending signature:

 

Date:

 

.

 

Attending: Ansari Atkisson Bowers Bruch Call Chang Cochrane Curran Ferraro Fuller Gilroy Hayes Kelly Knight Latham McCraw McFarland Meyer North-Coombes Schrank Sinopoli Smith Surka Von Hofe Wagstaff Watson Weber Weems White

Page 4 of 4

How to Edit History And Physical Form Online for Free

It won't be difficult to create printable history and physical template making use of our PDF editor. Here's how you can easily prepare your form.

Step 1: In order to start, click the orange button "Get Form Now".

Step 2: Now you will be on your document edit page. You can include, change, highlight, check, cross, include or remove areas or text.

Complete all of the following parts to fill in the document:

history and physical template fields to fill out

Enter the demanded information in Past MedicalSurgical History, Social History, and Family History area.

stage 2 to filling out history and physical template

You will be asked for specific essential particulars if you would like prepare the Page of field.

Entering details in history and physical template part 3

Step 3: Press the "Done" button. Finally, you can transfer your PDF file - save it to your device or forward it by using email.

Step 4: Make copies of your document - it will help you keep away from possible future troubles. And fear not - we do not distribute or check the information you have.

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