Posted at 17:09h
in
Nursing
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
HPI:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
SI/HI: _______________________________________________________________________________
Sleep: _________________________________________ Appetite: ________________________
Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________ Current perception of Health: Excellent Good Fair Poor
Psychiatric History:
Inpatient hospitalizations:
Date
Hospital
Diagnoses
Length of...