Annual Exam H&P Form (SUNY DMC)

Name: [text name="variable_83" default=""]
MRN: [text name="variable_84" default=""]

Chief complaint: [text name="variable_1" default=""]
History of present illness: 
[textarea name="variable_1" default=""]

Review of systems:
General: [textarea name="variable_65" default="denies fever/chills, fatigue, malaise, weight changes"]
HEENT: [textarea name="variable_66" default="denies headaches, vision changes, rhinorrhea, sore throat"]
Cardiac: [textarea name="variable_67" default="denies chest pain, palpitations, peripheral edema"]
Pulmonary: [textarea name="variable_68" default="denies shortness of breath, dyspnea, cough, sputum production"]
GI: [textarea name="variable_69" default="denies nausea/vomiting, abdominal pain, diarrhea/constipation, melena/hematochezia"]
GU: [textarea name="variable_70" default="denies dysuria, hematuria"]
MSK: [textarea name="variable_71" default="denies myalgias, arthralgias, weakness, numbness/tingling"]
Dermatologic: [textarea name="variable_72" default="denies rashes"]
Neurologic: [textarea name="variable_73" default="denies seizures"]
Psychiatric: [textarea name="variable_74" default="denies depression, anxiety"]
Endocrine: [textarea name="variable_75" default="denies polyphagia, polydipsia, polyuria"]
Hematologic/lymphatic: [textarea name="variable_76" default="denies abnormal bleeding/bruising"]

Past medical history: 
[textarea name="variable_3" default=""]

Past surgical history:
[textarea name="variable_56" default=""]

Allergies: 
[textarea name="variable_4" default=""]

Medications:
[textarea name="variable_5" default=""]

Pharmacy:
[textarea name="variable_57" default=""]

Social history:
Occupation - [text name="variable_41" default=""]
Living situation - [text name="variable_40" default=""]
Social services - [text name="variable_42" default=""]
Tobacco - [text name="variable_6" default=""]
Alcohol - [text name="variable_7" default=""]
Illicit drugs - [text name="variable_8" default=""]

Family history:
[text name="variable_58" default=""]

Vital signs: 
T - [text name="variable_10" default=""] F
BP – [text name="variable_9" default=""] mm Hg
HR - [text name="variable_11" default=""] bpm
RR - [text name="variable_12" default=""] brpm
SaO2 - [text name="variable_13" default=""]%

Physical examination
General: [textarea name="variable_77" default="AAOx3, NAD"]
HEENT: [textarea name="variable_78" default="NC/AT, PERRLA, EOMI, mmm, no LAD"]
Cardiovascular: [textarea name="variable_79" default="RRR, +s1, +s2, no M/R/G"]
Pulmonary: [textarea name="variable_80" default="CTA b/l, no W/R/R"]
Abdominal: [textarea name="variable_81" default="soft, NT/ND, no hepatosplenomegaly, +bowel sounds"]
Neurological/MSK/Extremities: [textarea name="variable_82" default="CN 2-12 intact, normal motor strength, normal sensation, normal reflexes "]

Significant laboratory values:
[textarea name="variable_85" default=""]

Radiology:
[textarea name="variable_36" default=""]

Microbiology:
[textarea name="variable_37" default=""]

Assessment
[textarea name="variable_38" default=""]

Plan
[textarea name="variable_39" default=""]

Health maintenance
Cancer screening:
- Colonoscopy: [text name="variable_43" default=""]

Vaccinations:
- Flu vaccine: [text name="variable_44" default=""]
- Pneumococcal (PPSV23/13): [text name="variable_45" default=""]
- Td/Tdap: [text name="variable_46" default=""]

For females: 
- Mammogram: [text name="variable_47" default=""]
- FRAX/QFracture Score: (If FRAX Score > 10%, get DEXA scan for osteoporosis); https://qfracture.org/ [text name="variable_48" default=""]
- Refer to Gyn for PAP smear if 21 or above: [text name="variable_49" default=""]

Other:
- ASCVD Score:  (if >7.5, start high intensity statin; if >10, add ASA) [text name="variable_50" default=""]
- PPD/Quantiferon (if high risk for TB, i.e, jail, homeless/lives in shelter, recent TB exposure): [text name="variable_51" default=""]

For diabetics:
- Refer to Ophthalmology for Glaucoma Screening/Diabetic Retinopathy if with h/o DM: [text name="variable_52" default=""]
- Refer to Podiatry for Podiatry Diabetic Foot Screening if with h/o DM: [text name="variable_53" default=""]

For smokers: 
- If 55-80 y/o who have a 30 pack-year smoking history & currently smoke or have quit w/in the past 15 years, LDCT: [text name="variable_54" default=""]
- >65 with h/o Smoking, send for US Abdomen for AAA screening: [text name="variable_55" default=""]

Counseling given on:
- Smoking and alcohol cessation and abstaining from substance abuse
- Driving with a seatbelt 
- Safe sex practices
- Regular exercise, i.e., low impact, stationary bike, swimming
- Medication compliance
- Weight reduction
- Dietary counseling: low-fat diet, decrease whole dairy products (whole milk, cheese, and butter), fatty meats, and fried foods. Eat more fruits, vegetables, whole-wheat breads, lean chicken, and fish (such as salmon or tuna).  Attempt at counting calories, use a calorie tracker such as MyFitnessPal, strive for 2700 kcal per day, small frequent meals, and avoid concentrated sweets.

RTC: [text name="variable_86" default=""]