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Patient Name [PatientName]
File Number [PatientID]
Nationality [Nationality]
DOB [DOB] / [Age]
Sex [Sex]
Insurance Provider [InsuranceProvider]
HISTORY AND PHYSICAL ASSESSMENT
CLINIC AND OUT-PATIENT DEPARTMENT
Date : [DoVisit]

Chief complaint(s) and History of Present Illness :

[HistoryOfComplaints]

CURRENT AND / OR PAST HEALTH PROBLEMS         

[CurPastHealthProblems]
Others : [HealthProbOthers]
Previous Hospitalizations / Past surgeries , specify (where / when / reasons) : [WWRRemarks]
Medication History: None. (Sepecify if any, include herbal and OTC medication)
[MedicationHistory]
ALLERGIES No Yes , Specify, [Allergies]

Family History :
[FamilyHistory]
 

PAEDIATRICS ONLY:
Exposure to infectious disease:
Chicken Pox Date :[ChickenPoxDate] None
TB Date :[TBDate] None
Pertussis Date :[PertussisDate] None
Immunization: Upto date Unsure No
Prenatal, Birth and Developmental History
[PrenatalBDHistory]
 

REVIEW OF SYSTEMS AND PHYSICAL EXAMINATION: (Pertinent to the patients' complaint)
[ReviewOfSystems] [PhysicalExamination]

DIAGNOSIS:
[Diagnosis]

PHYSICIAN ASSESSMENT AND PLAN:
[PhysicianAssessmentAndPlan]
DOCTOR'S SIGNATURE DOCTOR'S STAMP DATE
MED/F034, Rev. 1