1. NUR 5250
Standard History and Physical Form
Name MK Date: 10-15-12 Reliability: yes
DOB Gender: MALE
Ethnicity:
HISTORY
CC:
“My stomach is killing me.”
HPI:
O: low grade fever 2 days ago, bloody stools over last week, abdominal pain for 3 months
L: left side of abdomen
D: 2 days – 3 months, pain after a meal
C: abdominal pain increase in duration and intensity, pain as dull sharp cramping that radiates
down left side of the abdomen, moderate to severe constipation, severe bloody stools, low grade
fever.
A: works long hours, laxatives for constipation as needed
T: Acetaminophen 1000mg PRN for muscle aches – 1-2 times per month , last one taken wads
yesterday, one day ago.
Bisacodyl suppository PRN for constipation, last use 10 days ago.
Current Medications (prescribed, OTC, vitamins, supplements/herbals):
Acetaminophen 1000mg, PRN, for muscle aches, on average takes 1-2 monthly, last used one
day ago.
Bisacodyl suppository PRN, constipation, last used 10 days ago
Allergies (drugs, environment, foods, latex, IV contrast):
Vicoden – Nausea, Hives
PMH:
Childhood Illnesses:
Hospitalizations/Surgeries/Trauma:
1

2. SOCIAL HISTORY
Marital Status: Single Married Domestic Partner
Divorced Widowed
Cohabitants:
___________________________________________________________________
Children: _____________________________________________________________________
Education:
____________________________________________________________________
Occupation:
___________________________________________________________________
Interests/Activities: _____________________________________________________________
Exercise: Aerobic Weights ________________________________________________
Diet: Balanced Calcium __________________________________________________
Sleep/Rest: ______________ Caffeine: No Yes cups/day _________________________
Tobacco: No Yes PPD _______ # years _______ Quit Year _______________________
Smoking in home: Yes No __________________________________________________
ETOH: Yes No Daily Weekly Monthly # drinks ______________________
Recreational Drugs: ____________________________________________________________
Support Systems/Coping Skills: Adequate Inadequate
FAMILY HISTORY
Family History Unknown
Father:
_______________________________________________________________________
Mother:
_______________________________________________________________________
Siblings:
______________________________________________________________________
MGF:
________________________________________________________________________
MGM:
________________________________________________________________________
PGF:
_________________________________________________________________________
PGM:
________________________________________________________________________
Other:
________________________________________________________________________
Cultural/Religious Influences:
_____________________________________________________
_____________________________________________________________________________
_
* Include genogram
2

3. HEALTH MAINTENANCE HISTORY
Exam Last Date Results N/ Refused
A
Pap Test
Mammogram
SBE/TSE
Stool guaiac
Flex sig/Colonoscopy
CXR
ECG
Dental
Vision
Hearing
Lipid Profile
FBS
PSA
PPD
Immunizations (dates):
Td MMR/titers Hep B Polio
Varicella vaccine/chickenpox Influenza Pneumovax
Safety:
Seatbelt Use Cycling Helmet Sunscreen Occupational
Smoke Detectors Housing Dom. Violence Firearms
ROS: *note pertinent positive and negative findings
General Cardiovascular
Skin Respiratory
Eyes Gastrointestinal
Ears Genitourinary/Gynecological
Nose/Mouth/Throat Musculoskeletal
3

4. Breast Neurological
PHYSICAL EXAMINATION *address all significant pertinent and abnormal findings
Weight Temp BP BMI
Height Pulse Resp
General Appearance
Skin
4

5. HEENT
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Neurological
Other
ASSESSMENT AND PLAN
Diagnosis:
Differential Diagnoses:
5

6. Intervention:
Follow-up:
PERIODIC HEALTH SCREENING PLAN
Exam Performed Scheduled N/A Refused
Breast Exam
Mammogram
Pap Test
Prostate exam
Testicular exam
Digital rectal with stool guaiac
Flexible
Sigmoidoscopy/Colonoscopy
Bone Density
PPD
IMMUNIZATIONS
Immunizations current: Yes No
Vaccine Given Planned Refused
Td
Hepatitis B
Influenza
Pneumonia
Other:
HEALTH COUNSELING (check if discussed, describe any intervention)
Smoking cessation ____________________________________________________________
Alcohol/Drug Use ____________________________________________________________
Diet/Weight _________________________________________________________________
Vitamins/Calcium ____________________________________________________________
Periodic Dental/Vision care _____________________________________________________
Exercise/Sleep _______________________________________________________________
Sun exposure ________________________________________________________________
Seatbelts/Helmets ____________________________________________________________
Stress/Family issues __________________________________________________________
Safety: Weapons/Domestic Violence _____________________________________________
BSE/TSE ___________________________________________________________________
Sexual issues/risks ____________________________________________________________
Contraception ________________________________________________________________
6

7. Living Will/Power of atty/DNR __________________________________________________
LAB/STUDIES ORDERED
CXR Lipids Creat/BUN HbA1C
ECG CBC/diff LFTs TSH
Electrolytes FBS UA/UC
Other:
Provider’s Signature Date
Note dictated/written
7