Florida College of Integrative Medicine TEMPLATE

Patient:
Date of Birth:
Date:
Historian:
Visit Type:
Office Visit, Procedure
*Vital Signs*
BP:
Position:
Pulse:
Temp F:
Resp.:
Pulse Ox:
Ht Ft:
Ht In:
Wt Lb:
BMI:
Pain Score:
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*History of Present Illness*
This __ year old female presents with:
*1. *
*2. *
*3. *
*Chronic Problems*
*Past Medical/Surgical History*
Condition Year Procedure/Surgery
*Family History* (revised and updated)
*Social History*
*Allergies*
*Reviewed, no changes
Allergen/Ingredient: Brand: Reaction:
*No Known Allergies
*Review of Systems*