UPPER RESPIRATORY SYMPTOMS

SPANGDAHLEM AIR FORCE BASE

Location of Medical Records: Fam Prac 52nd 752nd 852nd
Date ____________
PCM:
Time____________
Work Phone______
________________ S: _____ y/o male/female c/o UPPER RESPIRATORY SYMPTOMS for ______ days.
Home Phone______ Subjective Exclusion Criteria for URI Nurse Managed Clinic:
________________ Book appointment for patient if any positive response.
Y/N SOB/Wheezing/Orthopnea
PRP Yes/No Y/N Newly swollen ankles or legs
Wt______________ Y/N Severe difficulty in swallowing
Y/N Unable to eat or drink
Ht______________ Y/N Ear Pain
T_______________ Y/N Hx of Asthma
Y/N Fever greater than 100.5 for five days or more
R_______________ Y/N Symptoms for more than two weeks
BP______________ Y/N Brown or bloody sputum
P_______________ Yes/No Thick, discolored nasal discharge
Yes/No Clear watery nasal discharge Yes/No Pain over sinus areas and upper teeth
Pulse Ox: _______% Yes/No Body aches Yes/No Pain worsens with bending over
Pain? Y/N Yes/No Headache Yes/No Post nasal drip
Yes/No Cough (dry / productive) Yes/No Sore throat
If Yes, rate 1-10: Yes/No Producing ________ phlegm Yes/No Tender, swollen lymph nodes
Complaint Yes/No Sneezing Yes/No Nausea / Vomiting (x ______)
Yes/No Itchy eyes, nose, or throat Yes/No Urinary symptoms
Deployment Yes/No Ill contacts Yes/No Diarrhea (x______)
Related? Y/N
PMH:
PHA: ___________ Yes/No Allergy problems
Tob Y/N Yes/No Sinus problems
Type____________ Home Treatment Tried:______________________________________________________________
Qty_____________
Freq____________ O:  Nurse Managed Clinic – Physical Exam Deferred
ETOH Y/N
Type____________ General: ___________________________________________________________________________
Qty_____________ Sinuses: Maxillary: nontender tender
Freq____________ Frontal: nontender tender
Allergies: Ears: Canals: Clear Cerumen Drainage Red
________________ TMs: Intact Perforated
Medications: Shiny Dull
________________ Gray Red
________________ Mobile Nonmobile
________________ - / + Fluid level
________________ Nares: Clear Red Pale Edematous Boggy
Discharge: clear / purulent
Throat: Pink Red Edematous Exudate

 HISTORY & PHYSICAL  OPERATION REPORT NAME

EXAMINATION (SF 516)
(SF 504, SF 505, & SF 506)
 CONSULTATION SHEET  NARRATIVE SUMMARY REGISTER NO. SSN
(SF-513) (SF 502)
STATUS
 CHRON RECORD OF  AUTOPSY PROTOCOL
MEDICAL CARE - (SF 600) (SF 503)
DATE TIME
 PROGRESS NOTE  EMG REPORT
(SF 509)

puter Rev. Jun 94 MEDICAL RECORD REPORT OPTIONAL FORM 275 (12 77)
Prescribed by G
FPMR (41 CF
 UPPER RESPIRATORY SYMPTOMS
SPANGDAHLEM AIR FORCE BASE
Location of Medical Records: Fam Prac 52nd 752nd 852nd

Tonsillar
size: ___/4
Symmetric:
Y/N
Uvula
midline: Y/N
Neck:
Supple
-/+
Lymphadenopathy
(anterior / posterior /
cervical)
Lungs:
CTA
Other:
_________________
_________________
______________
Heart:
RRR
No murmur
Other:
_________________
_________________

 HISTORY & PHYSICAL  OPERATION REPORT NAME

EXAMINATION (SF 516)
(SF 504, SF 505, & SF 506)
 CONSULTATION SHEET  NARRATIVE SUMMARY REGISTER NO. SSN
(SF-513) (SF 502)
STATUS
 CHRON RECORD OF  AUTOPSY PROTOCOL
MEDICAL CARE - (SF 600) (SF 503)
DATE TIME
 PROGRESS NOTE  EMG REPORT
(SF 509)

puter Rev. Jun 94 MEDICAL RECORD REPORT OPTIONAL FORM 275 (12 77)
Prescribed by G
FPMR (41 CF