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After completing, a detailed health history and complete physical examination students will write up the results of the health history and physical examination (SOAP note) using APA format. The health history form and details are as follow:FAMILY CLINIC.
A]
Name__________________________DOB____________________Soc
First Middle Last
Insurance: _________________________________Today’s Date_______________
Address:____________________City¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬_____________State___________Zip____
B] To be filled out by clinicians:
S:_________________________________________________________________
O: T___ Wt:_______ Ht:________ BP_______ P:_______ R:________ BMI:____
Body Fat%____ Belly fat %:_____ Muscle fat%:_____ BIO age:_____ Waist:____
Normal weight/Obese/Over weight to loose /Gain:_____ Diet/exercise:_______
HEENT:_______ Lungs: _____________Heart__________
Abdomen: ________OBGYN:____________ Skin: __________________________
A:________________________________________________________________
P: _______________________________________________________________
Comment: _____________________________________________RTC:
Clinician’sName_____________________________________
A]
Name__________________________DOB____________________Soc
First Middle Last
Insurance: _________________________________Today’s Date_______________
Address:____________________City¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬_____________State___________Zip____
B] To be filled out by clinicians:
S:_________________________________________________________________
O: T___ Wt:_______ Ht:________ BP_______ P:_______ R:________ BMI:____
Body Fat%____ Belly fat %:_____ Muscle fat%:_____ BIO age:_____ Waist:____
Normal weight/Obese/Over weight to loose /Gain:_____ Diet/exercise:_______
HEENT:_______ Lungs: _____________Heart__________
Abdomen: ________OBGYN:____________ Skin: __________________________
A:________________________________________________________________
P: _______________________________________________________________
Comment: _____________________________________________RTC:
Clinician’sName_____________________________________
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