Army Medical Health Record Form: History and Physical Exam Form

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Army Medical Health Record Form: History and Physical Exam Form. Blank.

Doc_type: 
Other
Rec_aclu_path: 
https://www.thetorturedatabase.org/node/2736
Doc_pdf_path: 
Doc_rel_date: 
Tuesday, March 22, 2005
Doc_text: 

History and Physical Exam Form
Name: ____________________ Date: _________________
ISN: ____________________ DOB: _____ AGE: ______ Gender: Male I Female Complaint: Acute: Chronic: Medications: VS: BP: Pulse: Resp: Temp: Height: Weight: PMH: DM Hosp: Surg: Allergies: HTN STD TB
SocHx: EtOH Tobacco YIN _____PPDx yrs
ROS: HEENT: CV: PULM: GI: GU: OB/GYN: MS: NEURO: DERM: ENDO: PSYCH: Physical Exam: HEENT: CV: PULM: GI: GU: OB/GYN: MS: NEURO: DERM: ENDO: PSYCH: Normal I Abnormal Normal I Abnormal Normal I Abnormal Normal I Abnormal Normal I Abnormal Normal I Abnormal INA Normal I Abnormal Normal I Abnormal Normal I Abnormal Normal I Abnormal Normal I Abnormal CXR: Normal I Abnormal Findings: PPD: Date placed: I Date read: I _____mm Immunizations: (given at this time) MMR Td Typhoid Polio Influenza Meningococcal Photograph
Comments I Findings:
Impression:

Plan:
Provider Signature: Printed Name I Stamp:
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.
DODDOA 026197

Doc_nid: 
2736
Doc_type_num: 
75