Get History And Physical Exam Form - New.docx

This guide provides comprehensive instructions on how to accurately complete the History And Physical Exam Form - NEW.docx online. Whether you are familiar with digital document management or new to this process, this guide will support you in successfully filling out the form.

Follow the steps to complete the form with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the client information section. Provide details such as the name, phone number, address, birthdate, and emergency contact information if applicable.
3. In the past medical history section, indicate any relevant medical history the client may have, including past illnesses or surgeries.
4. Record the current diagnosis/problems the client is facing. This includes any conditions that are affecting their current health.
5. List all current medications the client is taking, ensuring to include dosage and frequency for each medication.
6. Conduct a physical examination. Fill in the general observations, allergies, height, weight, blood pressure, and pulse findings. Assess and document findings for specific areas such as EENT, neck, chest, heart, abdomen, and extremities.
7. If there are special orders for the client, specify any dietary restrictions or safety measures that are required.
8. Complete the plan/prognosis section providing an overview of the expected health status and recommended actions moving forward.
9. Fill out the HEDIS measures section, documenting relevant screenings and health metrics for the client.
10. Conduct a tuberculosis examination if applicable, recording necessary screening dates and symptoms.
11. Finally, provide the physician's certification by documenting comments and obtaining the physician's signature along with the date.
12. After reviewing all sections for accuracy and completeness, save changes. You can choose to download, print, or share the completed form.

Complete your History And Physical Exam Form online today for a seamless and efficient experience.