advice health

1. complete physical examination that will be performed on a person that is 18 years old or older.

2. Submit a typed SOAP Note of the 18years old physical assessment. Make sure to follow the proper sequential order in your physical assessment and use the correct terminology in your SOAP Note. 

SOAP Note Template

Encounter date: ________________________

Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____

Reason for Seeking Health Care: ______________________________________________

HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________ Current perception of Health: Excellent Good Fair Poor

Past Medical History

· Major/Chronic Illnesses____________________________________________________

· Trauma/Injury ___________________________________________________________

· Hospitalizations __________________________________________________________

Past Surgical History___________________________________________________________

Medications: __________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Family History: ____________________________________________________________

Social history:

Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________ Employment Status: ______ Current/Previous occupation type: _________________

Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________

Sexual orientation: _______ Sexual Activity: ____ Contraception Use: ____________

Family Composition: Family/Mother/Father/Alone : _____________________________

Health Maintenance

Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____

Exposures:

Immunization HX:

Review of Systems:

General:

HEENT:

Neck:

Lungs:

Cardiovascular:

Breast:

GI:

Male/female genital:

GU:

Neuro:

Musculoskeletal:

Activity & Exercise:

Psychosocial:

Derm:

Nutrition:

Sleep/Rest:

LMP:

STI Hx:

Physical Exam

BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI ( percentile) _____

General:

HEENT:

Neck:

Pulmonary:

Cardiovascular:

Breast:

GI:

Male/female genital:

GU:

Neuro:

Musculoskeletal:

Derm:

Psychosocial:

Misc.

1. complete physical examination that will be performed on a person that is 18 years old or older.

2. Submit a typed SOAP Note of the 18years old physical assessment. Make sure to follow the proper sequential order in your physical assessment and use the correct terminology in your SOAP Note. 

SOAP Note Template

Encounter date: ________________________

Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____

Reason for Seeking Health Care: ______________________________________________

HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________ Current perception of Health: Excellent Good Fair Poor

Past Medical History

· Major/Chronic Illnesses____________________________________________________

· Trauma/Injury ___________________________________________________________

· Hospitalizations __________________________________________________________

Past Surgical History___________________________________________________________

Medications: __________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Family History: ____________________________________________________________

Social history:

Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________ Employment Status: ______ Current/Previous occupation type: _________________

Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________

Sexual orientation: _______ Sexual Activity: ____ Contraception Use: ____________

Family Composition: Family/Mother/Father/Alone : _____________________________

Health Maintenance

Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____

Exposures:

Immunization HX:

Review of Systems:

General:

HEENT:

Neck:

Lungs:

Cardiovascular:

Breast:

GI:

Male/female genital:

GU:

Neuro:

Musculoskeletal:

Activity & Exercise:

Psychosocial:

Derm:

Nutrition:

Sleep/Rest:

LMP:

STI Hx:

Physical Exam

BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI ( percentile) _____

General:

HEENT:

Neck:

Pulmonary:

Cardiovascular:

Breast:

GI:

Male/female genital:

GU:

Neuro:

Musculoskeletal:

Derm:

Psychosocial:

Misc.