H&P templates

[Koppma]

Does anyone know a good site that has any good template for H&P's that is good for the beginner? Thank you very much for your help.

[PYRITE]

this site has some decent templates to download: http://www.medfools.com

 

(go to downloads tab)

[winterallsummer]

Here is what I used when we first started doing these in school.  Nothing special but you can use it if you like or use it to get an idea of how you want of make your own.  This is obviously not practical for real life practice.

 

Date & Time:

Name:
DOB:

 

 

CC:

 

OPQRST

Onset:

Palliative (worse/better):

Quality:

Region/radiate:

Severity:

Time:

 

Assoc sx (& OPQRST)

 

 

 

PMH

 

Medical (MI, CAD, HTN, valvular heart disease,

stroke, migraine, mental health, substance abuse,

asthma, chronic bronchitis, emphysema, cancer

liver disease, hepatitis, renal disease, diabetes

peptic ulcer, arthritis, glaucoma, thyroid disorder)

 

Childhood

 

Adulthood (seasonal allergies go here)

 

Past blood transfusions (*hematologic section*):

 

Surgeries (type, date, where, complications, C sections, eye)

 

Hospitalizations (where, dx, tx)

 

Injury

 

 

 

Immunizations (when)

 

Health screening (when + result)

TB test

pap smear

mammogram

metabolic panels & blood work

 

 

 

Family History: alive, dead & cause of death, diabetes, cancer, heart, HTN, cholesterol, cancer

 

Social History:

Born where:

Live where:

Education/job:

Ethnicity:

Support system:

Sleep:

Diet:

Tobacco:

Alcohol:

Street drugs (cost or quantity):

Exercise:

Relationship status (& kids):

 

 

 

Drug allergies

 

Food allergies

 

 

 

Medication

Prescription:

 

OTC:

 

 

 

 

ROS (!!! PAST 6 MONTHS!!!)

 

General

Weight:

Weight changes (if unintentional, details):

Weakness:

Fatigue:

Fever:

Chills:

 

Skin

Lesions:

Rashes:

Pruritus (itching):

Bruise easily (*hematologic section*):

Dry/moist skin:

Changes in skin color:

Hair or nails abnormally brittle:

Change in size/color of moles:

Jaundice (yellow skin/eyes):

 

Head

New/unusual headache:

Trauma:

Lightheadedness

Dizziness:

 

Eyes

Vision:

Glasses/contacts (why needed?):

Last eye exam & results:

Pain:

Diplopia (dbl vision):

Blurred vision:

Scotomata (marks/blocks in field of vision):

Photophobia:

Excessive lacrimation:

Injection (redness):

Discharge:

Field cut:

Injury:

 

Ears

Pain/earache:

Discharge:

Vertigo (room spinning):

Tinnitus:

Hearing issues:

Past or recurrent infections:

 

Noses/Sinuses

Frequent colds:

Pain:

Discharge:

Injury:

Epistaxis (nosebleed):

Congestion:

 

Throat/Mouth/Pharynx

Condition of teeth/gums:

Dentures (& fit):

Last dental exam (& results):

Sore tongue:

Dry mouth:

Frequent sore throats:

Hoarseness:

 

Neck

Pain/stiffness:

Limitation of movement:

Goiter:

Lumps:

Swollen glands:

 

Respiratory

Cough:

Sputum (quality, color, odor):

Hemoptysis (cough up blood):

Wheezing:

Dyspnea (SOB):

Pleuritic chest pain:
Exposure to TB:

 

Cardiovascular

Chest pain:

Orthopnea (hard to breath when lying down):

Paroxysmal nocturnal dyspnea (wake up gasping for air & coughing):

Palpitations/irregular heartbeat:

 

GI

Dysphagia (hard to swallow):

Heartburn (relation to meals, use of antacids):

Appetite:

Nausea:

Vomiting (frequency, last time ingested foods, color, amount)

Hematemesis (vomiting blood):

Abdominal pain:

Excessive belching or gas:

Frequency of bowel habits:

Changes in bowel movements:

Stool color & frequency:

Tarry stools:

Painful defecation:

Rectal bleeding:

Hemorrhoids:

Tenesmus (frequent urge to pee or poop but nothing comes out):

 

Peripheral vascular

Intermittent claudication (tingling, pain, numbness in legs that comes & goes):

Leg cramps:

Varicose veins:

Edema/ulceration/hair loss/color change/coldness of calves, legs or feet:

Color changes in fingertips/toes:

 

Musculoskeletal (if positive - what muscle/joint area, any swelling, erythema, stiffness, weakness, limitation of movement, timing and duration of sx)

Trauma/injury:

Muscle or joint pain:

Stiffness:

Backache:

Redness:

Swelling:

 

Neurological:

Changes in mood, attention or speech:

Changes in orientation, memory or judgement:

Blackouts:

Paralysis:

Numbness/loss of sensation:

Tremor:

Clumsiness/balance problems:

Loss of coordination:

Paresthesia (tingling, numbess anywhere on body):

Gait changes:

 

Psychiatric

Nervousness:

Tension:

Depressed mood:

Anxiety:

Hallucinations:

Suicidal (thoughts to hurt self):

Homicidal (thoughts to hurt others):

 

Endocrine:

Heat or cold intolerance:

Changes in glove/shoe size:

Excessive perspiration (sweating):

Hirsutism (girls getting lots of hair on arms, legs etc):

Increased thirst/hunger:

 

Genitourinary - both

Lumbar/flank/suprapubic (think kidneys) pain:

Frequency of urination:

Polyuria (excess urine):

Nocturia (awake to pee at night often):

Urgency:

Changes in the force of the urinary system:

Incontinence:

Hesitancy:

Calculi (kidney stones):

Dysuria (painful peeing):

Hematuria (blood in pee):

 

MEN ONLY!

Dribbling:

Hernias:

Penile lesions or discharges:

Testicular pain/masses:

Prostate disease:

Scrotal pain:

Erection (achieve/maintain):

Ability to ejaculate:

 

WOMEN ONLY!

 

Breasts (female patients only!)

Breast self exam:

Masses:

Tenderness:

Nipple discharge/changes in areolar skin

 

Menarche (first one / any problems with):

Regularity/frequency/duration of menses (period):

Bleeding between menses or after intercourse:

Last menstrual period (LMP):

If menopausal → age at LMP, hormone replacement therapy, history of post-menopausal bleeding)

Dysmenorrhea (painful period):

Dyspareunia (painful sex):

Vaginal discharge/pruritus/lesions/lumps:

Vulvar lesions/pruritus/pain:

 

# of pregnancies (gravida):

# of viable births (para):

# of abortions & miscarriages:

Type of deliveries:

Complications during pregnancy/labor/delivery OR postpartum:

 

C sections → surgical; Deliveries → hospital

 

Sexual history

History and activity (men/women; oral/vaginal/anal):

Protection (condoms and/or BC):

HIV/STIs concerns; ever tested:

Frequency:

Satisfaction:

 

WASH HANDS!!!

 

[Guest]

Can you make your own? When we started we just used word to edit the packet with directions on how to do H&P. We just left a bunch of spaces after each field, and circled ROS and PMH stuff. Of course you have o elaborate on those but can always use the back of the page.