Medical Assessment Sheet
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.
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Full Name: Jake Willms
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Date of Birth: July 15, 1990
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Gender: Male
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Address: Arlington, TX 76001
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Phone Number: 222 555 7777
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Email Address: jake@you.mail
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Emergency Contact: Amelia Pagac, 222 555 7777
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Insurance Provider: HealthFirst Insurance
II. Medical History
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Current Medical Conditions:
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Hypertension
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Type 2 Diabetes
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Past Surgeries:
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Appendectomy, March 12, 2015
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Known Allergies:
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Penicillin
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Pollen
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Family History:
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Father: Heart Disease
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Mother: Breast Cancer (Remission)
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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
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Chief Complaints:
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Frequent headaches
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Occasional dizziness
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Symptoms Noted:
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Fatigue
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Mild shortness of breath after exercise
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Physical Exam Findings:
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Blood Pressure: 140/90 mmHg
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Pulse Rate: 82 beats per minute
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Temperature: 98.6°F
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V. Pre-Surgery Assessment
Before a scheduled procedure, the patient’s overall health and readiness for surgery are assessed in this section.
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Procedure Scheduled: Knee Replacement Surgery
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Scheduled Date: February 15, 2050
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Pre-Operative Tests Completed:
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Blood work: Normal
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Chest X-ray: Clear
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ECG: Normal
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Surgeon: Dr. Lance Nader
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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.
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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 |
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April 10, 2050 |
Dr. Lance Nader |
Recovery on track, slight discomfort |
Continue therapy |
May 10, 2050 |
VII. Emergency Room (ER) Triage
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Date of Visit: May 20, 2050
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Reason for Visit: Severe chest pain and shortness of breath
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Vital Signs:
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Blood Pressure: 150/95 mmHg
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Heart Rate: 120 beats per minute
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Oxygen Saturation: 95%
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Initial Diagnosis: Possible heart attack
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Immediate Care Plan: Administer oxygen, IV fluids, and prepare for an EKG
VIII. Insurance and Claims Processing
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Insurance Claim Number: 234567891
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Date of Service: January 05, 2050
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Procedure: Routine Check-up
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Claim Status: Pending approval
Prepared by: [YOUR NAME]
[YOUR EMAIL]
