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Patient Information Name: Mr. James Carter Age: 78 Gender: Male Ethnicity: African American Marital Status: Widowed Living Situation: Lives alone in a one-story home Insurance: Medicare Chief Complaint “I don’t feel like myself anymore… I just feel tired and alone.” History of Present Illness (HPI) Mr. Carter is a 78-year-old...

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...