Free Medical Examination Report Template
Medical Examination Report
[Your Company Name]
[Your Company Email]
123 Wellness Lane Springfield, IL 62701
Patient Information
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Name: [Patient's Name]
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Date of Birth: [Patient's Birthdate]
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Gender: Male
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Address: [Patient's Address]
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Phone Number: [Patient's Contact Number]
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Email: [Patient's Email]
Examination Details
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Date of Examination: October 1, 2024
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Referring Physician: Dr. Jane Smith
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Reason for Examination: Annual physical examination and routine health check-up
Medical History
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Allergies: None
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Current Medications: Lisinopril 10 mg daily for hypertension
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Past Medical History: Hypertension diagnosed in 2015, well-controlled; no surgeries
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Family History: Father with coronary artery disease; mother with type 2 diabetes
Physical Examination Findings
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Vital Signs:
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Blood Pressure: 120/80 mmHg
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Heart Rate: 72 bpm
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Respiratory Rate: 16 breaths/min
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Temperature: 98.6°F
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Height: 5 ft 10 in
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Weight: 180 lbs
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General Appearance: Patient appears healthy and well-nourished, in no acute distress.
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Head and Neck Examination: No abnormalities noted; throat clear, no lymphadenopathy.
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Cardiovascular Examination: Heart sounds normal; no murmurs or gallops. Peripheral pulses intact.
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Respiratory Examination: Clear lung fields bilaterally; no wheezing or crackles.
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Abdominal Examination: Soft, non-tender, no organomegaly, bowel sounds normal.
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Neurological Examination: Alert and oriented; cranial nerves intact, normal reflexes.
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Musculoskeletal Examination: Full range of motion, no swelling or tenderness.
Laboratory and Diagnostic Tests
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Blood Tests:
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Complete Blood Count: Normal
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Lipid Panel: Total Cholesterol 180 mg/dL, LDL 100 mg/dL, HDL 60 mg/dL
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Glucose: 90 mg/dL
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Urinalysis: Normal; no signs of infection or protein.
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Imaging Studies: Chest X-ray: Clear lungs, no acute abnormalities.
Assessment
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Summary of Findings: Overall healthy with well-controlled hypertension; no acute issues noted during the examination.
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Diagnosis: Essential hypertension, controlled; no additional medical conditions identified.
Recommendations
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Continue current medication (Lisinopril) and monitor blood pressure regularly.
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Maintain a balanced diet and regular exercise regimen to manage weight.
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Schedule follow-up in one year for the next annual examination or sooner if symptoms develop.
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Recommend a consultation with a nutritionist for dietary guidance.
Physician's Signature:
[Your Name]
Medical License Number: IL123456
October 2, 2068
