HISTORY:
Presents for a wellness visit
Current symptoms:
Medications:
Adherence: ,
Over-the-counter supplements: , ,
Past medical history:
Family history: , , , , ,
Social history:
Smoking: , pack-years
Alcohol: , drinks per
Recreational drugs: ,
Diet: , , , ,
Physical activity:
Weight: ,
Occupation:
Labs:
Creatinine:
Na: , K:
Hb:
HbA1c:
Lipids: , Cholesterol: , LDL: , HDL: , Triglycerides:
TSH:
PSA:
Urinalysis:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Measurements: weight: kg, height: cm, waist: cm, BMI:
Eyes: -R: , -L: ,
Ears: -R: , -L:
Nose:
Throat:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Anorectal: DRE , prostate , anus
Genital: , testicles , penis
Skin:
Extremities: , , cap refill , pulses ,
Musculoskeletal: joints ,
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , speech , mood , thought process , , judgment
ASSESSMENT:
PLAN:
- Colonoscopy
- FIT test
- Blood work: , , , , , , , , ,
- Dietary counseling: balanced diet rich in fruits, vegetables, lean proteins, and whole grains
- Exercise counseling: at least 150 minutes of moderate-intensity or 75 minutes of high-intensity aerobic activity per week, plus muscle-strengthening activities twice per week
- Weight management counseling
- Smoking cessation counseling
- Alcohol moderation counseling
- Vaccinations: annual , if aged ≥ 65 or conditions, if aged 50 and older, every 10 years,
- Medication renewal for months
- Follow-up in
- Return if new symptoms develop or condition worse