Name

Age

Gender

• Male

• Female

Phone Number

Email

1. General Health

• Patient appears well and alert

• No signs of distress

• Vital signs are within normal range

Reported symptoms

2. Medical History

• No known chronic conditions

• Known conditions

Known Conditions

List the known conditions.

Current Medications

List the current medications.

Allergies (if applicable)

3. Physical Examination

• Skin is clear, no rashes or lesions

• Eyes, ears, nose, and throat appear normal

• Heart and lungs sound normal

Other findings

4. Pain Assessment

5. Mobility and Function

• Full range of motion

• Limited range of motion

• Needs assistance with mobility

• No issues with daily activities

6. Mental Health

• Patient is oriented to time, place, and person

• Reports no feelings of anxiety or depression

• Displays signs of stress or emotional distress

• Requires mental health referral

7. Recommendations

• No immediate action required

• Follow-up appointment needed

• Referral to specialist required

• Lifestyle recommendations given

Action Items

List any concerns or follow-up actions.

Rate the patient’s overall health status.