Fillable HISTORY & PHYSICAL LONG FORM / COMPREHENSIVE (UCLA Health)

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HISTORY & PHYSICAL LONG FORM / COMPREHENSIVE (UCLA Health)

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HISTORY & PHYSICAL
LONG FORM / COMPREHENSIVE
(Comprehensive H&P required for all admissions > 24 Hours
UCLA Form #316042 Rev. (7/13) Page 1 of 2
MRN:
Patient Name:
(Patient Label)
Date: Time: Service:
Chief Complaint:
History of Present Illness:
Allergies:
Medications:
Past Medical History: (N/C = non-contributory) N/C CAD CVA HTN DM Other:
Past Surgical History: N/C
Family History: N/C
Relevant Social History: N/C ETOH IVDA Tobacco _____ Packs x ______ yrs
Review of Systems CHECK ALL APPROPRIATE BOXES
GENERAL:
WNL Other
SKIN:
WNL Other
ENT:
WNL Other
EYES:
WNL Other
CV:
WNL Other
RESP:
WNL Other
GI:
WNL Other
GU:
WNL Other
Muscl:
WNL Other
Neuro:
WNL Other
Hemat/Lymph:
WNL Other
Examining Practitioner: Date: Time: Pager #:
Attending MD: Date: Time: Pager #:
HISTORY & PHYSICAL
LONG FORM / COMPREHENSIVE
(Comprehensive H&P required for all admissions > 24 Hours
UCLA Form #316042 Rev. (7/13) Page 2 of 2
MRN:
Patient Name:
(Patient Label)
Allergic/Immuno:
WNL Reactions to: Drugs Food Insects Skin rashes
Trouble breathing Persistent infections HIV exposure
Endo:
WNL Diabetes Thyroid Dysfunction
Psych:
WNL Nervousness Anxiety Depression Previous psych care Hallucinations
Other:
Physical Exam: CHECK ALL APPROPRIATE BOXES
V
ital Signs: B/P P R T
General:
WNL Other
Height: _____________ Weight: ______________
ENT:
WNL Other
Eyes:
WNL Other
Breasts:
WNL
Other
Lungs:
WNL Other
Heart:
WNL Other
Abd:
WNL Other
Musculo-
Skeletal:
WNL
Other
Genitalia:
WNL Other
Neurologic:
WNL Other
Skin/wounds:
WNL Other
Labs: Studies:
CXR:
EKG:
Impression:
Plan:
Examining Practitioner: Date: Time: Pager #:
Attending MD: Date: Time: Pager #:
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HISTORY & PHYSICAL LONG FORM COMPREHENSIVE (UCLA Health)

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Completed 29 August 2021

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