Full Name:

John Casper

Date of Birth (DOB):

07/15/2050

Gender:

Male

Phone:

222 555 7777

Email:

john@you.mail

Address:

Madison, WI 53701

Emergency Contact Name:

Susan Casper

Emergency Contact Relation:

Spouse

Emergency Contact Phone:

222 555 7777

Allergies:

Penicillin

Chronic Conditions:

Hypertension, Type 2 Diabetes

Past Surgeries/Procedures:

Knee replacement (2085), Appendectomy (2063)

Family Medical History:

Father: Heart Disease, Mother: Osteoporosis

Current Medications:

Metformin 500 mg (daily), Losartan 50 mg (daily)

Date of Visit:

03/12/2090

Reason for Visit:

Routine diabetes and blood pressure check-up

Symptoms Described by Patient:

Occasional dizziness and fatigue

Physical Exam Findings:

Blood Pressure: 145/90 mmHg, Weight: 210 lbs, Blood Sugar: 145 mg/dL

Diagnosis:

Uncontrolled hypertension and suboptimal diabetes management

Treatment Plan:

Adjust Losartan to 100 mg (daily), recommend dietary changes and exercise

Follow-Up Instructions:

Monitor BP daily, schedule visit in 6 weeks

Next Appointment Date:

04/23/2090

HbA1c Test

03/10/2090

HbA1c: 7.8% (elevated)

Dr. Laura C. Monroe

Metformin

500 mg

Once daily

Ongoing

Losartan

100 mg

Once daily

Ongoing

Date:

03/12/2090

Updates on Patient Condition:

Patient reports compliance with medications but challenges in maintaining diet.

Changes to Treatment Plan:

Increased Losartan dosage from 50 mg to 100 mg due to elevated blood pressure.

Physician Name:

Dr. Laura Monroe

License Number:

2090123456

Date Signed:

03/12/2090

Miscellaneous Information:

Patient requested additional resources for dietary management and stress reduction techniques.

Prepared By:

[YOUR NAME], [YOUR COMPANY NAME]

Date Prepared:

03/12/2090