Notes

subjective:
onset
location
duration
characteristics
aggravating/relieving factors
timing
severity

past medical history
past surgical history
family history
social history
allergies:
medications:
immunizations:
Review of systems:
General: fever, chills, sweat, fatigue, weight +/-
HEENT: headaches, dizziness, changes in vision, blurry vision, ear pain, hearing difficulties, nasal drainage, changes or difficulty with smell, sore throat, changes in taste, or dental complaints, voice change
lymph: swollen, painful lymph nodes
lungs: Shortness of breath, difficulty breathing, cough, wheezing, sputum
Cardiac: chest pain, palpitations, edema, claudication (cramping pain in legs), hypertension, hyperlipidemia
GI: reflux, nausea, vomiting, abd pain, diarrhea, constipation, changes in bowel habits, pain swallowing
Endocrine: heat/cold intolerance, fatigue, weight chx, polydipsia, -uria, -phagia
GU: chx in urinary habits, problems with urine, UTIs
MSK: pain, stiffness, heat, swelling bones/joints. muscle/shoulder pain
neuro: numbness, tingling, syncope, dizziness, tremors
psych: depression, mood swings, concentration problems

Mental status: A/Ox3
Integumentary:
HEENT: head is normocephalic and symmetrical. Facial features are symmetrical. Tympanic membranes clear and intact bilaterally, minimal cerumen build up, no pineal pain. No nasal swelling externally or internally, no polyps, turbinates, drainage, crusting, or tenderness. Oropharynx is without erythema, drainage, exudates. Soft palate rises when patient says, “ahh,” uvula midline. Positive gag reflex.
Lymphatic system: no lymphadenopathy.
Lungs/chest: chest is symmetrical, respirations are even, nonlabored and with ease. Lungs resonant to percussion posteriorly. Lungs are clear to auscultation without wheezes, rhonchi, or rales
Cardiac/vascular: normal S1 and S2, regular rate and rhythm, no murmurs, gallops, carotid or abdominal bruits, JVD, clicks, snaps, heaves, or thrills. PMI is palpated at the 5ICS, midclavicular line. 2+ radial, carotid, and dorsalis pedal pulses bilaterally. No noted swelling, varicosities, coolness, or pallor or lower extremities.
Abdomen: soft, nontender, flat, nondistended, positive bowel sounds x4 quadrants,
Musculoskeletal system: body parts appear symmetrical, spine appears with straight alignment without any curving. Positive ROM of upper and lower extremities. Normal muscle mass and tone. No noted crepitus, tenderness, or swelling of joints.
Neurological: symmetrical gait