HISTORY & PHYSICAL LONG FORM / COMPREHENSIVE

HISTORY & PHYSICAL LONG FORM / COMPREHENSIVE

(Comprehensive H&P required for all admissions > 24 Hours

Date: Chief Complaint:

Time:

History of Present Illness:

MRN: Patient Name:

Service:

(Patient Label)

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: GI:

WNL WNL

Other Other

GU:

WNL Other

Muscl: Neuro:

WNL WNL

Hemat/Lymph:

WNL

Examining Practitioner: Attending MD:

Other Other Other

UCLA Form #316042 Rev. (7/13)

Date: Date:

Time: Time:

Pager #: Pager #:

Page 1 of 2

MRN: Patient Name:

HISTORY & PHYSICAL LONG FORM / COMPREHENSIVE

(Comprehensive H&P required for all admissions > 24 Hours

Allergic/Immuno:

Endo: Psych: Other:

WNL

Reactions to:

Trouble breathing

WNL

Diabetes

WNL

Nervousness

Drugs

Food

Persistent infections

Thyroid Dysfunction

Anxiety

Depression

(Patient Label)

Insects HIV exposure

Skin rashes

Previous psych care

Hallucinations

Physical Exam: CHECK ALL APPROPRIATE BOXES

General:

WNL

Other

ENT:

WNL

Other

Eyes: Breasts:

WNL WNL

Other Other

Lungs:

WNL

Other

Heart: Abd:

WNL WNL

Other Other

MusculoSkeletal: Genitalia:

Neurologic:

Skin/wounds:

WNL

WNL WNL WNL

Other

Other Other Other

Vital Signs: B/P Height: _____________

P

R

T

Weight: ______________

Labs: Impression:

Studies: CXR: EKG:

Plan:

Examining Practitioner: Attending MD:

UCLA Form #316042 Rev. (7/13)

Date: Date:

Time: Time:

Pager #: Pager #:

Page 2 of 2

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