Outpatient Examination Form

# Outpatient Examination Form

Patient ID: ________________   Date: ________________

## Vitals
- BP: ____/____ mmHg
- Pulse: ____ bpm
- Temp: ____ °F
- Resp Rate: ____ /min
- O2 Sat: ____% on: [ ] Room air  [ ] __ L O2

## Chief Complaint
______________________________________________

## History of Present Illness
______________________________________________
______________________________________________
______________________________________________

## Review of Systems
[ ] Constitutional  [ ] HEENT  [ ] Cardiovascular  [ ] Respiratory
[ ] Gastrointestinal  [ ] Genitourinary  [ ] Musculoskeletal
[ ] Neurological  [ ] Psychiatric  [ ] Endocrine  [ ] Hematologic
[ ] Allergic/Immunologic

Notes: _________________________________________

## Physical Examination

```
       O
      /|\    Front           Back
     / | \   ____            ____
     \ | /  |    |          |    |
      \|/   |    |          |    |
       |    |    |          |    |
      / \   |____|          |____|
     /   \

    Head ___________   Neck ___________
    Chest __________   Back ___________
    Abd ____________   Extremities ____
```

## Assessment
______________________________________________
______________________________________________

## Plan
1. __________________________________________
2. __________________________________________
3. __________________________________________

## Medications
[ ] No changes
[ ] Changes (specify): _________________________

## Follow-up
[ ] 1 week  [ ] 2 weeks  [ ] 1 month  [ ] 3 months  [ ] As needed

Additional Notes:
______________________________________________
______________________________________________

Provider Signature: ___________________________