[Clinic Date] 19/8/2020

[Patient Name] ashref hessen [MRN] 1279

[Provisional Diagnosis] 53

Past Medical History (circle all that applies)

None☐ Anxiety☐ High Cholesterol☐ Allergy: Food☐

Heart Disease☐ Bleeding Difficulties☐ Seizure☐ Allergy: ☐Seasonal

High Blood Pressure☐ Hepatitis A B or C☐ Loss of Consciousness☐ TB☐

Stroke/TIA☐ HIV☐ Arthritis (Type) ☐ Hypothyroid☐

Obstructive Sleep Apnea☐ Diabetes-Diet Controlled☐ Asthma☐ Hyperthyroid☐

Coronary Artery Disease☐ Diabetes-Oral Meds☐ Emphysema☐

Depression☐ Diabetes-On Insulin☐ Osteoporosis☐

If you answer yes to any of the above please provide details

none

o Cancer: Type/Treatment:

o Other (Specify):
none

Past Surgical History

(Type of Surgery & Year)

Prescription Medications

Medication Dose/Number per Day Medication Dose/Number per Day

Non-Prescription Medications
Medication Dose/Number per Day Medication Dose/Number per Day

- -
Drug Allergies /Type of Reaction

none

Social History
(Please check the appropriate listings)
Tobacco Use Choose an item.
o Never☐
o Quit/When?
o Cigarettes/Pack per Day?

Occupational History/ Education

Employer: Job Title (Year):

Is the patient on sick leave?

Family History

Father Living☐ Medical History High Blood Pressure☐ Diabetes☐ Cholesterol☐

Deceased☐ Age: or Cause of Cancer: Type Other
Death
Mother Living☐ Medical History High Blood Pressure☐ Diabetes☐ Cholesterol☐
Deceased☐ Age: or Cause of Cancer: Type Other
Death
Brothers Living ☐ Medical History High Blood Pressure☐ Diabetes☐ Cholesterol☐
Deceased ☐ Age: or Cause of Cancer: Type Other
5 Death
Sisters Living ☐ Medical History High Blood Pressure☐ Diabetes☐ Cholesterol☐
Deceased ☐ Age: or Cause of Cancer: Type Other
5 Death

For Females: Date of first MP:Click here to enter text. Date of last MP:Click here to enter text.
Pregnant☐ No. of pregnancies/deliveries:Click here to enter text.
Type of birth control:Click here to enter text.
Last PAP:Click here to enter text.
Last Mammogram:Click here to enter text.
Last bone density scan:Click here to enter text.
First MP : when she was years .
Last MP : from .
No Of Pregnancies :
No Of Deliveries : ( ) Male ( ) female
Chief Complaint / History of Present Illness

Review of systems
Constitutional symptoms Cardiovascular Psychiatric
Fever/Chills☐ Chest pain☐ Depression☐
Weight loss☐ Difficulty breathing☐ Anxiety☐
Headache☐ Swelling ☐ Suicide☐
Palpitations☐

Eyes Respiratory Skin

Blurred vision☐ wheezing☐ Rash/sores☐
Double vision☐ Shortness of breath☐ Mole changes☐
Vision changes☐ Cough☐
Sleep apnea☐

Allergic/Immunologic Musculo-skeletal Breast

Hay fever☐ Joint pain☐ Nipple discharge☐
Medications☐ Muscle weakness ☐ Lumps☐
Muscle pain☐ Skin changes☐

Neurologic ENT Genitourinary

Dizziness☐ Sore throat ☐ Urine leakage ☐
Seizures ☐ Sinus problems ☐ Urine retention ☐
Numbness/tingling ☐ Hearing problems ☐ burning micturition ☐
Excessive thirst ☐ Frequent urination ☐
Hot flashes ☐
Endocrine Hematologic/Lymphatic Vaginal discharge ☐
Hair loss ☐ Swollen glands ☐ abnormal bleeding ☐
Heat/cold intolerance ☐ Frequent bruising ☐ Painful periods ☐
Painful intercourse ☐
Gastro-intestinal Fibroids ☐
Nausea/vomiting ☐ Infertility ☐
Constipation/diarrhea ☐
Abdominal pain ☐
If the answer is yes to any of the above, please provide details below

Physical Examination
VITAL SIGNS:
Pulse BP Temp Weight Height

• General
General appearance
Posture
• Head and Neck
Eyes
Tongue
Cheek
Pallor
Cyanosis
Edema
Swelling
Redness
Rash
• Cervical lymph nodes: encircle the groups enlarged and specify consistency and relation to surrounding structures
• Cardiovascular
Regular rhythm ☐
Murmurs ☐
JVD ☐
Carotid bruits ☐
• Lungs and chest
Accessory muscles ☐
Wheezes ☐
Auscultation ☐
• Skin
Rashes ☐
Warm ☐
Dry ☐
Erythematous areas ☐
• Breast

• Abdomen
Scars ☐
Visible bulges ☐
Dilated veins ☐
Scars ☐
Hernia orifices ☐
Back ☐
Tenderness ☐
Organomegaly ☐
Normal bowel sounds ☐
• Genito-Urinary
Performed ☐ not performed ☐
• Rectal
Performed ☐ not performed ☐
• Extremities
Edema ☐
Clubbing ☐
• Musculo Skeletal
Strength ☐
Range of movements ☐
Joints ☐
• Neurological
Alert ☐
 Oriented ☐
CN 2 – 12 ☐
Local Examination

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Essential labs
HB WBC Platelets PT PTT INR

FBS Urea Creatinine Albumin Bilirubin

ALK phosph

Others

Tumor Markers
CEA CA 19-9 CA 125 Alpha Fetoprotein

LDH HE4 HCG

Others

Endoscopy Findings
 Imaging:

Pathology

Plan