Get History & Physical Format

Filling out the History & Physical Format is a crucial step in documenting a person's medical history and presenting a comprehensive overview of their health status. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to fill out the History & Physical Format online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the identification section with the person's name, address, telephone number, date of birth, informant, and referring provider.
3. Move on to the chief complaint section. List all symptoms and their duration, explaining the reason for seeking care.
4. In the history of present illness section (HPI), utilize the PQRST method to detail the symptoms: identify provocative/palliative factors, describe quality/quantity, specify the region of discomfort, rate severity, and note timing.
5. Complete the past medical/surgical history, detailing any prior health issues or surgeries, including weight changes, illnesses, and operations.
6. List any known allergies and medications, including both prescription and over-the-counter drugs.
7. In the social history section, provide information about the person's birthplace, residency, education, occupation, marital status, and substance use including alcohol and drugs.
8. Conduct the CAGE review to assess potential alcohol use issues by answering the questions regarding cutting down, annoyance by criticism, guilt feelings, and morning alcohol use.
9. Include family history, mentioning ages and causes of death of relatives and any family diseases.
10. Proceed to the review of systems, documenting any issues across various body systems, like skin, eyes, cardiovascular, gastrointestinal, and neurological.
11. Finally, after filling out all sections of the form, save the changes. Depending on your requirements, you can download, print, or share the completed form.

Start filling out the History & Physical Format online today for prompt and accurate documentation.