Exam History, Facts, and Concerns

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Abbreviationsà

Sx=Surgery

Hx=History

F=Familial

C=Current

R=Resolved

 

/d= per day

/wk = per week

d/d=drops/day

D/C=Discontinue

SE=Side Effects

Date:

Scars:      

       

Congenital defects:        

       

Surgeries:       

       

Cravings:        

      

Allergies:        

 

 

Date:

Challenges, Concerns, Historical Medical Issues (Please list only one per line)

   
   

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


  

 

 

 

 

 

 

 

 

 

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