Drug Allergies & Special Considerations :
List of Drugs & Other Products Tried :
Constitutional-General Appearance:
Build, Nutrition, Posture, Grooming (Normal?)
Vital Signs Wt. Pulse, BP, Temp (Normal?)
Neuro/Psychiatric:
Alert & Oriented in T/S/P (Normal?)
Mood and Affect (Normal?)
Hair & Seat Glands:
Scalp & Body Hair (Normal?)
Eccrine & Apocrine Glands (Normal?)
Ear, Nose, Mouth & Throat:
Lips, Teeth and Gums (Normal?)
Oropharynx (Normal?)
Gastrointestinal:
No anal growths or fissures (Normal?)
No hepatosplenomegally (Normal?)
Skin & Subcutaneous Tissues are Normal:
Head & Face:
Neck:
Chest, Breast & Axillae:
Abdomen:
Genitalia. Groin & Buttocks:
Right Upper Extremity:
Left Upper Extremity:
Right Lower Extremity:
Left Lower Extremity:
Eyes: Eyelids and Conjunctivae (Normal?)
Neck: Thyroid, nodules or masses (Normal?)
Cardiovascular(Peripheral): No edema, Circulation ok (Normal?)
Extremities: No digital cyanosis or clubbing (Normal?)
Lymph Nodes: 1-Neck 2-Axillae 3-Groin (Normal?)
Clinical History & Diagnostic Studies reviewed:
Clinical Impression
Follow Up :
Management Plan
Chaperone & Scribe
Dermatologist
Pertinent Details (Photo &/or Audiovisual documentation) :