Title Page

  • Patient Name

  • Assigned Medical Practitioner

  • Conducted on

  • Location

Subjective Data

  • Age

  • Race

  • Gender

  • Chief complaint

  • History of Present Illness (location, quality, severity, timing, setting, alleviating/ aggravating factors, associated signs and symptoms)

  • Past Medical History (allergies, current medication, injuries, hospitializations, surgeries)

  • Family History

  • Social History

  • Review of Systems

Objective Data

  • Height (in)

  • Weight (lbs)

  • BMI

  • Temperature

  • Blood Pressure (BP)

  • General Appearance

  • EENT (Eyes, Ears, Nose, Throat)

  • Cardiovascular

  • Respiratory

  • Integument/ Lymphatic Inspection

  • Laboratory Results


  • General Observations

  • Differential Diagnosis


  • Treatment Plan


  • Name & Signature of Attending Medical Practitioner

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.