Medical Assessment Sheet

I. Patient Information

The Medical Assessment Sheet begins with basic patient details. This information is essential for identifying and tracking the patient.

Full Name: Jake Willms
Date of Birth: July 15, 1990
Gender: Male
Address: Arlington, TX 76001
Phone Number: 222 555 7777
Email Address: jake@you.mail
Emergency Contact: Amelia Pagac, 222 555 7777
Insurance Provider: HealthFirst Insurance

II. Medical History

Current Medical Conditions:
- Hypertension
- Type 2 Diabetes
Past Surgeries:
- Appendectomy, March 12, 2015
Known Allergies:
- Penicillin
- Pollen
Family History:
- Father: Heart Disease
- Mother: Breast Cancer (Remission)

III. Current Medications

List of medications the patient is currently taking to manage health conditions.

Medication Name	Dosage	Frequency	Start Date	Prescribing Doctor
Lisinopril	10 mg	Once daily	June 01, 2020	Dr. Maxwell Mante
Metformin	500 mg	Twice daily	January 10, 2023	Dr. Orval Grimes
Aspirin	81 mg	Once daily	April 05, 2023	Dr. Orval Grimes

IV. Initial Patient Evaluation

Chief Complaints:
- Frequent headaches
- Occasional dizziness
Symptoms Noted:
- Fatigue
- Mild shortness of breath after exercise
Physical Exam Findings:
- Blood Pressure: 140/90 mmHg
- Pulse Rate: 82 beats per minute
- Temperature: 98.6°F

V. Pre-Surgery Assessment

Before a scheduled procedure, the patient’s overall health and readiness for surgery are assessed in this section.

Procedure Scheduled: Knee Replacement Surgery
Scheduled Date: February 15, 2050
Pre-Operative Tests Completed:
- Blood work: Normal
- Chest X-ray: Clear
- ECG: Normal
Surgeon: Dr. Lance Nader
Anesthesiologist: Dr. Jackie Tillman

VI. Follow-Up Appointments

A record of any subsequent visits for follow-up care after treatment or surgery. This ensures proper healing and addresses any concerns post-procedure.

Date of Visit	Doctor's Name	Key Observations	Treatment Plan	Next Appointment Date
March 10, 2050	Dr. Lance Nader	Mild swelling around the knee joint	Physical therapy	April 10, 2050
April 10, 2050	Dr. Lance Nader	Recovery on track, slight discomfort	Continue therapy	May 10, 2050

VII. Emergency Room (ER) Triage

Date of Visit: May 20, 2050
Reason for Visit: Severe chest pain and shortness of breath
Vital Signs:
- Blood Pressure: 150/95 mmHg
- Heart Rate: 120 beats per minute
- Oxygen Saturation: 95%
Initial Diagnosis: Possible heart attack
Immediate Care Plan: Administer oxygen, IV fluids, and prepare for an EKG