Name:

Age:

Address:

1. Medical History

• Review of past medical conditions, medications, surgeries, allergies, and family medical history.

2. Physical Examination

• A thorough examination of the body systems, including inspection, palpation, percussion, and auscultation.

3. Vital Signs

• Measurement of blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation.

4. Diagnostic Tests

• Ordering and interpretation of laboratory tests, imaging studies, and other diagnostic procedures.

5. Assessment of Symptoms

• Evaluation of current symptoms reported by the patient, including their severity, duration, and impact on daily life.

6. Review of Systems

• Systematic assessment of various body systems to identify any signs or symptoms of disease or dysfunction.

7. Functional Status

• Evaluation of the individual's ability to perform activities of daily living, mobility, and functional independence.

8. Laboratory Results

• Review and interpretation of blood tests, urine tests, and other laboratory investigations.

9. Imaging Studies

• Interpretation of X-rays, CT scans, MRI scans, ultrasound, or other imaging modalities to visualize internal structures.

10. Nutritional Assessment

• Evaluation of dietary habits, nutritional status, weight history, and risk factors for malnutrition or nutritional deficiencies.

11. Medication Review

• Review of current medications, including prescription drugs, over-the-counter medications, and supplements.

12. Immunization Status

• Assessment of immunization history and compliance with recommended vaccinations.

13. Psychological Evaluation

• Screening for mental health conditions, cognitive function, mood disorders, and psychosocial stressors.

14. Social History

• Exploration of social support networks, living arrangements, employment status, education, and lifestyle factors.

15. Family Medical History

• Documentation of significant medical conditions, hereditary diseases, and health-related factors affecting family members.