Patient Diagnosis Diet: Lab: Activity: Treatments: IV Orders: MEDICATION ORDERS: Diabetes: Type I Insu in: " ood

sugar ##########
)* +* ,* -* .* /* 0* 1* 2*

Gender

Age

Doctor

ALLERGIES: Type II !edication: " ood sugar ########## " ood sugar########## reason %or giving Time's( to give

!edication$dose$route$%re&uency

CHIEF COMPLAINT/PRESENT ILLNESS '34y t4e patient is 4ere( HISTORY 'past i ness5 in6uries5 4ospita i7ations5 surgery5 s eep patterns5 %ami y( GENERAL: 8orma 9eig4t ##### "$P####### Pu se##### Respirations###### Temperature##### SKIN 'ras4es5 itc4ing5 4ives5 bruising5 ec7ema5 dryness5 s:in co or c4anges5 4air te;ture
c4anges5 nai te;ture c4anges5 appearance o% nai s 'inc uding toes(5 previous s:in disorders5 umps5 use o% 4air dyes(

EYES, NOSE, EARS 'eyeg asses5 redness5 prob ems 3it4 vision5 eye disc4arge5 g aucoma5
cataracts5 ast eye e;am5 eye in6uries5 nasa disc4arge5 noseb eeds5 sinus in%ections5 4ay %ever5 nasa obstruction5 %re&uency o% co ds5 4earing aid5 4ard o% 4earing5 dea%ness5 ringing in ears5 di77iness5 ear disc4arge5 pain in ears(

PERRLA#####

MOUTH AND THROAT 'condition o% teet4 and gums5 bad breat45 prob ems 3it4 c4e3ing
or eating5 ast denta e;am5 %re&uency o% sore t4roats5 c4anges in voice5 persistent 4oarseness5 t4yroid prob ems5 goiter5 umps5 pain in nec:5 s3o en g ands(

BREAST ' umps5 disc4arge5 pain5 %re&uency o% se % e;am( CARDIOVASCULAR 'c4est pain5 pa pitations5 murmurs5 4ig4 b ood pressure5 s4ortness o%

breat4 3it4 e;ertion or ying do3n5 4istory o% 4eart attac: or r4eumatic %ever5 varicose veins5 pain in egs or ca ves 3it4 3a :ing5 s3e ing in egs or %eet5 coo ness o% an e;tremity5 oss o% 4air on egs5 disco oration o% an e;tremity5 u cers(

<R regu ar irregu ar ##### S, #### S- #### murmur ####

RESPIRATORY 'coug45 34ee7ing5 sputum amount and co or5 b oody sputum5 s4ortness o%
breat45 ast4ma5 p eurisy5 bronc4itis5 T"5 ast c4est =>ray5 ast T" s:in test(

Pu se O;#### O+#### % at$round$distended bo3e sounds? yes no Pain ocation Last "!#####

GASTROINTESTINAL 'recent 3eig4t

oss5 appetite5 4eartburn5 be c4ing5 nausea5 vomiting5 abdomina pain5 constipation5 c4ange in co or or consistency o% stoo 5 %re&uency o% stoo 5 4emorr4oids5 recta b eeding5 use o% a;atives5 6aundice5 4epatitis5 ga b adder prob ems(

GENITOURINARY 'co or and odor o% urine5 %re&uency5 urgency5 di%%icu ty starting stream5

stress incontinence5 e;cessive5 pain%u or burning urination5 b ood in urine5 % an: pain5 3a:ing at nig4t to urinate5 retention5 :idney stones5 @TIs5 STDs5 MALES prostate prob ems5 se % e;am o% testic es5 FEMALES onset o% menses5 %re&uency and engt4 o% periods5 date o% menopause5 pregnancies$miscarriages5 use o% birt4 contro 5 date o% ast PAP(

MUSCULOSKELETAL 'pain or sti%%ness in 6oints5 3ea:ness5 de%ormities5

imitations in abi ity to ambu ate and trans%er5 6oint c ic:ing5 musc e cramps or spasms5 use o% assistive devices5 use o% prost4esis5 prob ems 3it4 ba ance5 4istory o% gout5 art4ritis5 bursitis or %ractures5 abi ity to carry out ADLs(

NEUROLOGICAL '4eadac4e5 %ainting5 di77iness5 ata;ia5 b ac:outs5 para ysis5 numbness5

ting ing5 burning5 tremors5 memory oss5 mood c4anges5 nervousness5 speec4 prob ems5 oss o% consciousness5 4a ucinations5 visua disturbances5 disorientation5 4istory o% brain in6ury or stro:e(

Orientation <and grips? L R Aacia symmetry

Notes:_____________________________________________________________________