Blank Clinical Assessment Sheet
Blank Clinical Assessment Sheet
Prepared by:
Email:
Date:
I. Patient Information
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Full Name:
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Date of Birth:
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Age:
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Gender:
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Contact Number:
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Email Address:
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Emergency Contact:
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Emergency Contact Number:
II. Medical History
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Past Medical Conditions:
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Surgical History:
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Allergies:
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III. Current Medications
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Medication Name |
Dosage |
Frequency |
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IV. Reason for Visit
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Primary Concern:
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Symptoms:
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Duration:
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V. Physical Examination
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Height:
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Weight: lbs
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Blood Pressure: mmHg
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Heart Rate: bpm
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Respiratory Rate: breaths per minute
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Temperature: °F
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General Appearance:
VI. Diagnostic Tests and Results
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Chest X-Ray:
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ECG:
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Blood Work (Complete Blood Count):
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Hemoglobin: g/dL
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WBC: /mm³
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Platelets: /mm³
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Pulmonary Function Test:
VII. Plan and Recommendations
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Referral:
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Follow-up Appointment:
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Lifestyle Changes:
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Medications Adjustment:
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VIII. Summary and Conclusion
This assessment provides an overview of the patient's medical status, including existing conditions, current symptoms, and recent diagnostic results. Ongoing monitoring and additional cardiology evaluation are recommended for further management of the patient's health.
